Adult ENT Health Questionnaire

Referring or family physician’s name:____________________________________________________________________
Why are you seeing the doctor today?__________________________________________________________________
Please list any medications you are currently taking (Including over the counter or herbal)
Are you allergic to any medications? NO____ YES_____ List:_______________________________________________
Have you ever had surgery? NO___ YES___ List:________________________________________________________
Any problems with Anesthesia? NO___ YES___ List______________________________________________________
Any hospitalizations? No___ YES___ List_______________________________________________________________
Occupation:___________________ Any pets indoors? NO___ YES___ List___________________________________
Do you smoke or use chewing tobacco? (circle which one)
Do you drink alcohol?
No____or quit____when quit?_____________________
NO___ YES____ List number of drinks/ day_________________________________________
Family History: (Circle if your family has had any of the following problems)
Hearing Loss
Problems with Anesthesia
Ear Tubes
Head/Neck Cancer
Thyroid Problems
High Blood Pressure
Heart Disease
Bleeding Problems
Personal History: (Please circle if you have had or currently have any of the following problems).
Constitutional: fevers, sweats, malaise, weight loss, change in appetite
Eyes: new vision problems, double vision, cataracts
ENT: ears, nose, throat
Cardiovascular: murmur, congenital heart disease, heart attack, chest pain.
Respiratory: cough, asthma, tuberculosis, shortness of breath, wheezing
Gastrointestinal: trouble eating, nausea, vomiting, diarrhea, abdominal pain,
acid reflux, indigestion
Genitourinary: recent infections, difficulty urinating, frequent urination
Musculoskeletal: arthritis, joint pain, mobility problems
Integumentary: skin infections, rashes, skin changes
Neurological: seizures, headaches, vertigo, weakness, stroke, developmental delay
Psychiatric: ADHD, anxiety, depression, drug dependence
Endocrine: diabetes, thyroid problems
Hematologic/ Lymphatic: bleeding disorders, easy bruising
Allergic/ Immunologic: immune problems, food allergy, environmental allergy, eczema,
Patient Label