New Patient Paperwork Name ________________________________________________________________________ Family Physician: ____________________ Address: __________________________________
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New Patient Paperwork Office Use Only: Patient Name: MR# Name ________________________________________________________________________ Family Physician: ____________________ Address: __________________________________ Referring Physician: __________________ Address: __________________________________ Medical Problem Today:_________________________________________________________ Have you received treatment for this problem before? __________________________________ Allergies to Medicines: ____________________________________________________ Please list all medications that you are currently taking – prescription and over the counter Medications: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ___________________________________________________________________ Please include name of medication, dosage (ie: 10mg, 25mg, etc), and how often taken Social History: Job Environment/Description: _______________________________________________________________ Do you use any heartburn or anti-reflux medications? Yes ____ Female – Are you pregnant now? Yes ____ No _____ No ____ Medical History Yes No Yes Allergies Angiodema (welts) Arthritis Eczema (dry, itchy skin) Headaches Hearing Loss Asthma High blood pressure (hypertension) Cancer Chronic lung disease Diabetes Bleeding disorder Other Medical History Ear infections Chronic ear infections Rashes/skin problem Please complete front and back No Yes Recurrent URI Seizures Sinusitis-Acute Sinusitis-Chronic (constant) Strep throat (recurrent) Urticaria (hives) No Surgical History Yes No Yes No Adenoidectomy Appendectomy Yes Hysterectomy Mastiodectomy Middle ear reconstruction Myringotomy Myringotomy w/tubes Bronchosocopy Cholecystectomy Colonoscopy Endoscopic sinus surgery Other Surgical History Septal button Septoplasty Tonsillectomy Turbinate reduction Tympanoplasty Tobacco: Do you smoke? No How much do you smoke? Less than 1 pack/day Have you ever smoked? No Yes If yes, for how many years? ___________ 1 pack/day or more 2 packs/day or more > 3 packs/day Yes If yes, for how many years? How many years ago did you quit? _________ Do you use any other kind of tobacco? Chewing Tobacco No Yes If yes, what kind? Snuff/Dip Cigars Pipe Other ________ Alcohol: Do you drink alcohol? Never Rarely Several times a month Several time a week Please complete front and back Daily Urticaria (hives) Thyroid disease Stroke Seizures Rheumatoid arthritis Rashes Osteoarthritis Migraines (severe headaches) Immunodeficiencies High Blood Pressure (Hypertension) Heart failure Hyperlipidemia Eczema Diabetes Cancer Atopy (allergic person) Asthma Angioedema (welts) Relationship Mother Father Brother Sister Maternal grandmother Maternal grandfather Paternal grandmother Paternal grandfather Allergic Rhinitis (allergies of the nose) Family History No New Patient Paperwork Office Use Only: Patient Name: MR# Review of Systems: Please check any symptoms you currently experience: General Health/ Constitutional None Change in Activity Change in Appetite Chills Diaphoresis (excessive sweating) Fatigue Fever Change in weight Eyes None Eye discharge Eye itching Eye pain Head, Ears, Nose and Throat None Facial Swelling Neck Pain Neck stiffness Ear Discharge Hearing loss Ear Pain Tinnitus Nosebleeds Congestion Rhinorrhea Postnasal drip Sneezing Sinus pressure Dental problem Drooling Mouth sores Sore Throat Trouble swallowing Voice change Respiratory None Apnea Chest tightness Choking Cough Shortness of breath Stridor Wheezing Cardiovascular None Chest Pain Leg swelling Palpitations Gastrointestinal None Abdominal distention Abdominal pain Anal bleeding Blood in stool Constipation Diarrhea Nausea Rectal pain Vomiting Neurological None Dizziness Facial asymmetry Headaches Light-headedness Numbness Seizures Speech difficulty Syncope Tremors Weakness Endocrine/Metabolic None Heat or Cold Intolerance Hair Change Excessive Thirst Skin None Color change Pallor Rash Wound Eye redness Photophobia (sensitivity to light) Visual disturbance Please complete front and back Muscular/Skeletal None Arthralgias Back pain Gait problem Joint swelling Myalgias Genital Urinary None Difficulty urinating Dyspareunia Dysuria Enuresis Flank pain Frequency Genital sore Hematuria Menstrual problem Pelvic pain Urgency Urine decreased Vaginal bleeding Vaginal discharge Vaginal pain Hematologic None Adenopathy Bruises/bleeds easily Psychiatric/Emotional None Agitation Behavior problem Confusion Decreased concentration Dysphoric mood Hallucinations Hyperactive Nervous/anxious Self-injury Sleep disturbance Suicidal ideas Please complete front and back
