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Patient Name: _______________________________________ DOB: / / Date: ______/_______/________ What is the reason you are here today? ____________________________________________________________________________ REVIEW OF SYSTEMS: General Health Problems: none fever chills sweats anorexia fatigue sleepiness sleep problems malaise weight gain weight loss speech delay Ear Problems: none itching pain fullness/pressure hearing loss wax ringing/noise in ears drainage Nose & Sinus Problems: none obstruction congestion post-nasal drip headache facial pain bleeding runny nose cough seasonal allergies Throat & Mouth Problems: none soreness pain swallowing difficulty voice problem bad breath snoring heartburn foreign body sensation tumor Skin Problems: none rash itching ulcers/growths excess scarring bleeding problems dryness suspicious lesions Allergic/Immunologic Problems: none urticaria (hives) hay fever persistent infections HIV exposure Neurologic Problems: none paralysis weakness paresthesias seizures syncope (fainting) tremors vertigo Vestibular Problems: none imbalance visual problems joint problems spinning sensation dizziness falling strength issues Eye Problems: none eye pain vision loss excessive tears blurring double-vision irritation discharge photophobia Neck Problems: none lump/mass thyroid problems pain tenderness Respiratory Problems: none cough dyspnea (difficulty breathing) excessive sputum hemoptysis (coughing up blood) wheezing ALL PAST OR PRESENT MEDICAL CONDITIONS: Condition Personal Alcoholism Allergic Rhinitis Anemia Anxiety Arthritis Asthma Atrial Fibrillation Cancer: Type(s) ________________ Carpal Tunnel Syndrome Chest Pain Circulatory System Disorder Congestive Heart Failure Depression Diabetes: Type I or II Ear Infections Emphysema Esophageal Reflux (Heartburn) Gout Grave’s Disease Headache Hearing Loss Heart Attack Heart Murmur Herniated Disc High Blood Pressure High Cholesterol High Lipids Hyper/Hypothyroidism Insomnia Irritable Bowel Syndrome Kidney Failure Liver Failure Migraine Obstructive Sleep Apnea Osteoporosis Sinusitis Stroke Vertigo OTHER: ___________________________ ______________________________________ ______________________________________ Family LIST ALL SURGERIES AND THE YEAR(S) PERFORMED: Surgery Year(s) Adenoidectomy Aneurysm Repair Appendectomy Artery Bypass Bone Fracture Repair Brain Surgery Breast Surgery C-Section Cancer Surgery Carotid Artery Surgery Carpal Tunnel Repair Cataract Removal Disc Surgery Ear Tubes Gallbladder Removal Heart Bypass Hip Replacement Hysterectomy Joint Replacement Knee Surgery Lung Surgery Mastoidectomy Neck Surgery Orthopedic Surgery Prostate Surgery Septoplasty Shoulder Surgery Sinus Surgery Stomach Surgery Thyroidectomy Tonsillectomy Tubal Ligation Valve Replacement Wisdom Teeth Removal OTHER: _______________ ____________________________ ____________________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Patient Name: __________________________________________ DOB: _______________________________ ARE YOUR IMMUNIZATIONS UP TO DATE? Yes TOBACCO USE HISTORY: ALCOHOL USE HISTORY: Check all that applies: Current Every Day Smoker Current Some Day Smoker Former Smoker Current Every Day Smokeless Tobacco User Current Some Day Smokeless Tobacco User Former Smokeless Tobacco User Never Smoker/Smokeless Tobacco User Current Exposure to Second-Hand Smoke Past Exposure to Second-Hand Smoke Check all that applies: Do you drink alcohol? Yes Frequency: Socially No No Minimally Infrequently Frequently DRUG USE HISTORY: Check all that applies: Do you use drugs? Current Use Past Use Never Used Type of Drug: Marijuana Hallucinogens Opiates Barbiturates Height: __________’ ____________” Amphetamines Cocaine OTHER: ________ Weight: __________ lbs. PLEASE LIST ALL MEDICATIONS YOU ARE TAKING (Including prescriptions, over-the-counter medications, and herbal supplements) IF NO CURRENT MEDICATIONS – CHECK: Name of Medication: NO CURRENT MEDICATIONS Dose: Frequency: PLEASE LIST ALL OF YOUR ALLERGIES IF NO KNOWN DRUG ALLERGIES – CHECK: NO KNOWN DRUG ALLERGIES Allergic To: Reaction: Severity (Check One): Low High Life-Threatening Low High Life-Threatening Low High Life-Threatening Low Low High High Life-Threatening Life-Threatening
