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Primary Care and Referring Physician Information Please give the following information so the physician you see today can communicate with your primary care doctor and/or referring physician. Primary Care Physician (PCP): Name ________________________________________________________ Address ________________________________________________________ City/State ________________________________________________________ Phone ________________________________________________________ Where you referred by a doctor to be seen here today? ____________________ Were you referred by your PCP? ________________________________________ If not your PCP, please list the following information: Referring Physician Name: _____________________________________________ Name ________________________________________________________ Address ________________________________________________________ City/State ________________________________________________________ Phone ________________________________________________________ Rush Otolaryngology Head and Neck Surgery Adult - Initial History Date: _______________________ Chief Complaint: What is the reason for your visit today (e.g. sinusitis, ear problem)? Medical History: Do you currently have or have you ever had any of the following conditions? High Blood Pressure (Hypertension) Heart disease Heart Attack Pacemaker Stroke Asthma COPD/emphysema Environmental Allergies Anemia Bleeding disorder Deep Vein Thrombosis (DVT, Blood Clot) Seizures Migraines Cancer Kidney problems Thyroid Problems Diabetes Lupus Rheumatoid Arthritis Arthritis Osteoporosis Tuberculosis HIV/AIDS Hepatitis Head Injury/Trauma Yes No ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Surgical History: YES NO Have you had your tonsils or adenoids removed? Have you ever had ear tubes placed? Have you had any other ear, nose or throat surgery? Please list any other surgeries you had in the past: ___ ___ ___ ___ ___ ___ Surgery Date Social History: Smoking Do you smoke or have you every smoked? If yes, how many packs/day? How many years? Date of last use? ____________________________________ ____________________________________ ____________________________________ ____________________________________ Chewing Tobacco or other types of tobacco Have you ever used chewing tobacco? If yes, for how many years? ____________________________________ ____________________________________ Alcohol Alcohol Use: Never ___ Types : Beer ___ Frequency: Rarely ___ Last drink(approximately): Years you have been drinking: Quit date(approximately): Currently ___ Former ___ Wine ___ Liquor ___ Daily ___ Weekly ___ Monthly ___ ________________________________________________ ________________________________________________ ________________________________________________ Drug Use Have you ever used? Cocaine ___ Heroin ___ Other Illicit Drugs ___ Family History: Do any first degree relatives have a history of the following (if yes, please list which person)? Environmental Allergies ________________________________________________ Early onset hearing loss ________________________________________________ Bleeding disorders ________________________________________________ Allergic reactions to anesthesia ________________________________________________ Cancer ________________________________________________ Allergies: Do you have any known drug allergies? Please list any known allergies to medications: Drug Yes ___ No ___ Type of Reaction Medications: Do you take Aspirin? _____________ Do you take any NSAIDS (e.g. Ibuprofen, Advil, Motrin, Alleve)? _______________ Do you take any blood-thinners (e.g. Warfarin, Coumadin, Plavix)? ____________ Please list all prescription medications you are currently taking. Please include any ear drops, inhalers, nasal sprays, or over the counter medications such as cold medications, decongestants, allergy medicines, vitamins? Drug Dose Review of Systems: Please check any of the following symptoms you are currently experiencing: Constitutional: Fevers Night sweats/Chills Weight loss Weight gain Fatigue Eyes Blurry vision Double vision Cardiac: Chest pain Palpitations Pulmonary: Wheezing Shortness of breath Cough Coughing up blood Gastrointestinal: Abdominal pain Vomiting Diarrhea Constipation Neurology: Headaches Weakness in your hands or legs Numbness in your hands or legs Dermatology: New onset rashes New skin lesions Heme: Easy bleeding or bruising Allergy: Itchy watery eyes Sneezing Yes No ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___