ASSOCIATED ENT PATIENT HEALTH HISTORY
Full Name ___________________________________________________ DOB _________ Height _________ Weight _________
What is the main reason you are seeing the doctor today?_________________________________________
ARE YOU ALLERGIC TO ANY MEDICATIONS?
Name of Medication
No
Yes If yes, please list below.
Type of Reaction
NON-MEDICATION ALLERGIES:
Are you allergic to anything in the environment such as grass, dust, or food?
No
Yes
If yes, please indicate what you are allergic to. ____________________________________________________________________
Are you allergic to Latex?
No
Yes
Are you allergic to IV Contrast Dye?
No
Yes
CURRENT MEDICATIONS: Are you taking ANY medications now?
No
Yes
dosage.
(This includes prescription, over-the-counter and herbal medications)
Medication Name
Dosage
Do you take Aspirin daily
No
Yes
If yes, please list below including
How often taken
Dose:
TESTS AND IMMUNIZATIONS:
Are your immunizations up to date? (CHILDREN ONLY)
No
Yes
PAST HEALTH HISTORY: Have you ever been DIAGNOSED with any of the following problems?
ALLERGIC RHINITIS / HAY FEVER
ANEMIA/BLOOD DISORDER
ANEURYSM
ANXIETY DISORDER
ASTHMA
ATHEROSCLEROSIS
AUTOIMMUNE DISORDER
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
BLEEDING DISORDER
No
Yes
BOWEL PROBLEMS
No
Yes
CANCER
No
Yes
SPECIFY:______________________________________
CARDIAC ARRHYTHMIA /
ATRIAL FIBRILLATION
No
Yes
CAROTID BLOCKAGE
No
Yes
CORONARY ARTERY DISEASE
No
Yes
DIABETES, TYPE I or II (circle)
No
Yes
EAR PROBLEMS
No
Yes
HEART DISEASE/ HEART ATTACK/
CONGESTIVE HEART FAILURE
No
Yes
HEARTBURN / REFLUX
HEPATITIS / LIVER DISEASE
HIV/AIDS
HYPERTENSION
KIDNEY DISEASE
MIGRAINES
NASAL POLYPS
NERVE DISEASE
NOSEBLEEDS
PULMONARY DISEASE / COPD /
EMPHESEMA
RECURRENT EAR INFECTIONS
RECURRENT SINUSITIS
RECURRENT TONSILLITIS
SEIZURES
SKIN PROBLEMS
SLEEP APNEA
STROKE
THYROID DISEASE
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
FAMILY HISTORY: Do any of your family members have any of the medical illnesses listed above?
RELATIONSHIP:
Mother:
Father:
Sister:
Brother:
Child:
No
Yes
No
Yes
MEDICAL ILLNESSES:
SOCIAL HISTORY:
Have you ever used Tobacco in any form?
How Many
Type of Tobacco
Years
Packs of Cigarettes a day: ___
Other: (list type) ___________
Do you use Recreational Drugs?
DO YOU CURRENTLY HAVE:
FEVER:
DOUBLE VISION:
DIFFICULTY HEARING:
RUNNY NOSE:
HOARSENESS:
HEADACHES:
CHEST PAIN:
SHORTNESS OF BREATH:
VOMITING:
BLEEDING PROBLEMS:
MUSCLE ACHES:
RASH:
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
No
Yes
Year Quit
No
Yes
Do you consume Alcohol?
Type of Alcohol
How
Much
Are you exposed to Second Hand Smoke?
How Often
No
Yes
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
SURGERIES AND HOSPITALIZATIONS:
Have you or any family member ever had any problems with anesthesia (being numbed or put to sleep)?
No
Yes
If yes, please list the problems that occurred. _____________________________________________________________________
HAVE YOU EVER HAD ANY OF THE FOLLOWING SURGERIES?
EARS:
EAR TUBES
NO
YES
OTHER EAR SURGERY: _____
_______________
NOSE AND SINUS:
NASAL POLYP REMOVAL
NO
YES
SINUS SURGERY
NO
YES
SEPTOPLASTY
NO
YES
OTHER NASAL SURGERY: _________________________
MOUTH AND THROAT:
ADENOIDECTOMY
NO
YES
TONSILLECTOMY
NO
YES
OTHER MOUTH OR THROAT SURGERY: _____________
NECK:
PAROTID GLAND REMOVAL
NO
YES
SUBMANDIBULAR GLAND REMOVAL
NO
YES
THYROIDECTOMY (PARTIAL / TOTAL)
NO
YES
OTHER NECK SURGERY: ________________
HEART AND BLOOD VESSEL:
HEART SURGERY
NO
YES
VASCULAR SURGERY
NO
YES
CANCER SURGERY:
NO
YES
TYPE:
YEAR:
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
THORACIC:
RESECTION OF LUNG TUMOR
NO
YES
OTHER LUNG SURGERY: _________________________
ABDOMINAL/ GENITOURINARY:
HERNIA REPAIR
NO
YES
GALLBLADDER REMOVAL
NO
YES
LIVER SURGERY
NO
YES
PANCREAS SURGERY
NO
YES
SPLEEN REMOVAL
NO
YES
APPENDECTOMY
NO
YES
COLON RESECTION
NO
YES
BARIATRIC SURGERY
NO
YES
PROSTATE SURGERY
NO
YES
HYSTERECTOMY
NO
YES
TUBAL LIGATION
NO
YES
OTHER ABDOMINAL/GENITOURINARY SURGERY:
YEAR:
________
________
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
________
BONE:
BACK SURGERY
NO
YES _______
OTHER BONE SURGERY: _________________________
BRAIN SURGERY
NO
YES _______
OTHER SURGERY:___________
___________________