Stanford Sinus Center New Patient Questionnaire

advertisement
STANFORD SINUS CENTER NEW PATIENT QUESTIONNAIRE
801 Welch Rd., Stanford, CA 94305
INSTRUCTIONS: Please answer all of the questions to the best of your ability before
you come to your appointment. All responses will be kept strictly confidential.
1. What is the reason for your appointment?
__________________________________________________________
What problem is bothering you the most?
__________________________________________________________
How long has it been bothering you?
__________________________________________________________
Who are you referred by?
________Self ______Doctor
Name___________________________
2. Do you have FACIAL PAIN OR PRESSURE?
Y
N
If so, please answer the following questions:
a. On which side is your discomfort more prominent? R
L
Both
b. How severe is it?
Mild
Moderate
Severe
c. Where do you have discomfort? (Check all that apply)
______ Between the eyes
______ Temple
______ Cheeks
______ Forehead
______ Around/behind the eye
______ Other: ___________________
______ Back of the head
d. Has a physician ever diagnosed you with migraines?
Y
N
e. Can you distinguish your migraines from your sinus pain?
Y
N
3. Do you have NASAL CONGESTION or BLOCKED BREATHING?
Y
N
If so, which side is more affected? Right
Left
Both equally
4. Do you have NASAL DISCHARGE or POST-NASAL DRIP?
How would you describe it?
5. How is your SENSE OF SMELL?
Clear
Discolored
Normal
Copyright Stanford Medicine. All rights reserved.
Diminished
Y
N
Bloody
Absent
6. Check all of the following symptoms that apply to you:
______ Headache
______ Fatigue
______Ear pressure
______ Fever
______ Dental pain
______ Nosebleeds
______ Bad breath
______ Cough
7. Do you have hay fever or other allergy symptoms?
Y
N
Have you ever been tested for allergies?
Y
N
When? _______________________
If yes, please list your allergies:________________________________________
Did you receive allergy shots? __________ If yes, how long?_________ Did they help? ______
8. Do you have RECURRENT INFECTIONS? Y
N
If so, please list all the antibiotics you have taken for sinus
infections:_____________________________________________________________________________________
_________________________________________________________________________________________________
The longest period of time that you have been on a single antibiotic is:
<2 weeks
2-4 weeks
4 - 8 weeks
More than 8 weeks
9. PAST MEDICAL HISTORY
Do you have or have you been treated for any of the following?
____ asthma
____ heart disease
____ high blood pressure
____ gastritis/ulcers
____cancer (type: _________________________________)
____ fibromyalgia
____ stroke
____ osteoporosis
____ low/high thyroid
____ liver disease
____ depression
____ immunodeficiency
____ kidney disease
____ diabetes
____ seizures
____ bleeding disorder
____ cataracts
____ hepatitis (type______) ____ glaucoma
Please list any other health problems not listed above:
________________________________________________________________________
________________________________________________________________________
10. HOSPITALIZATIONS AND OPERATIONS
Date
Reason/Procedure
Hospital
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
11. CURRENT MEDICATIONS (please include any vitamins or herbal medications)
Name
Dose
Frequency
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Copyright Stanford Medicine. All rights reserved.
12. MEDICATION ALLERGIES
List any medication allergies and the type of reaction that occurs:
________________________________________________________________________
________________________________________________________________________
____ NONE KNOWN
13. FAMILY HISTORY: Please check all that apply to your family members
____ Allergy
____ Sinus disease
____ Asthma
____ Cystic fibrosis
____ Immunodeficiency
____ Bleeding disorder
____ Cancer (Type and relationship of family members: ________________________)
____ Other (List _____________________________________________________________________)
14. SOCIAL HISTORY:
a. Your occupation: ______________________________
b. Do you smoke? Y N
If yes, # packs per day? ___/#___ years?
Did you ever smoke in the past? Y N If yes, # packs per day? ___/#___ years?
c. Do you drink alcohol? Y N If yes, # drinks per day? ________
d. Have you ever used any other addictive substances? Y
N
If yes, what drug(s)? _______________________________________________________________
15. REVIEW OF SYSTEMS: Please circle any of the health problems that pertain
to you.
Ears:
Ringing
Dizziness
Drainage
Mouth/Throat:
Pain or difficulty swallowing
Hoarseness
Cardiopulmonary:
Chest Pain
Palpitations
Genitourinary:
Burning on urination
Gastrointestinal:
Heartburn
Abdominal pain
Hearing loss
No Symptoms
Lumps in Neck
No Symptoms
Heart murmur
Cough
Frequency of urination
Vomiting
No Symptoms
Shortness of breath
No Symptoms
No Symptoms
Diarrhea
Psychological: Depression No Symptoms
Sleep pattern:
Snoring
Daytime sleepiness Stop breathing during sleep
Copyright Stanford Medicine. All rights reserved.
No Symptoms
Endocrine:
Heat intolerance
Cold intolerance
Eyes:
Recent change in vision
Excessive thirst
Impaired vision
Neurologic:
Weakness
Numbness
Musculoskeletal:
TMJ disorder
Arthritis
General:
Nausea
Weight gain
Fever
Weight loss
Skin:
Skin Cancer
No Symptoms
Double vision
No Symptoms
No Symptoms
Fatigue
No Symptoms
Hematologic/Lymphatic:
Swollen Lymph Nodes
Allergic/Immunologic:
Hepatitis
Frequent Infections
Copyright Stanford Medicine. All rights reserved.
Immune Disorders
No Symptoms
No Symptoms
Download