ANTERIOR NECK/NASOPHARYNX
Last Name: _____________________________ First Name: __________________ Date: ______
1. Have you had a CT scan of the area of interest? _______________________________________
If yes, when __________________________ What did it show? ________________________
2. What does your doctor think may be causing your problem? _____________________________
____________________________________________________________________________
____________________________________________________________________________
3. Describe your symptom (pain, mass, weight change, etc.)________________________________
____________________________________________________________________________
4. Does anything make the symptoms worse?
_________________________________________
______________________________________________________________________________
5. Does anything make them better? _________________________________________________
_____________________________________________________________________________
6. Have you had a biopsy or surgery? ______________ When? ____________________________
What was done? ________________________________________________________________
Results? _______________________________________________________________________
7. Are you taking any medicines?
□ Yes □ No
If yes, what kind: _______________________________________________________________
____________________________________________________________________________
8. Do you have any other medical conditions?
□ Yes □ No
If yes, what? ___________________________________________________________________
9. Describe your general health: _____________________________________________________
PLEASE COMPLETE BOTH SIDES