Download Ear/Nose/Throat

Albany Community Health Clinic
920 E. Sheridan St., Suite A
Laramie, WY 82070
(307) 460 – 9039
Email: [email protected]
Patient Medical Information Initial Intake
Full Name:
Date of Birth:
Reason for today’s visit:
Current Medications
Medication
Example:
Lisinopril
Dose
How Often
10 mg
1 a day
Allergies to Medications (please circle) YES / NO
Medication
Dose
If so, to what drug(s) and with what reaction(s):
Past Medical History (Please √ only if you have a history of any of the following
□ ADHD
□ Alcohol Use Disorder
□ Allergic Rhinitis
□ Asthma
□ Atrial Fibrillation
□ Anemia
□ Anxiety
□ Autoimmune Disorder
Revised 8/2015
How Often
□ Bipolar Disorder
□ Blood Transfusion
□ Brain Tumor
□ Cirrhosis
□ Chronic Renal Failure
□ COPD
□ Colon Cancer
□ Coronary Heart Disease
□ Crohns Disease
□ Stroke
□ Depression
□ Diabetes – Child/Insulin
□ Diabetes – Adult Onset
□ Diverticulitis/Diverticulosis
□ DVT/Blood Clots in Legs
□ Ear Infection Recurrent
□ GI Bleed Upper
□ GI Bleed Lower
□ GERD (Reflux)
□ Heart Failure
□ Hemochromatosis
□ High Cholesterol
□ High Blood Pressure
□ Hyperthyroidism
□ Hypothyroidism
□ Hepatitis, Type ____
□ Inflammatory Bowel Disease
□ Irritable Bowel Syndrome
□ Kidney Disease
□ Kidney Stone(s)
□ Liver Disease
□ Metabolic Syndrome
□ Heart Attack (MI)
□ Neurologic Disorder
__________________
□ Osteoarthritis
□ Osteoporosis
□ Pancreatitis
□ Peripheral Vascular Disease
□ Peptic Ulcer Disease
□ Rheumatoid Arthritis
□ Seizure Disorder
□ Tuberculosis History
□ Ulcerative Colitis
□ UTI - Recurrent
□ Valvular Heart Disease
□ Varicose Veins/Phlebitis
□ Abnormal Pap Smear
Have you had any of the following Surgeries (Please √):
□ AAA Repair
□Abdominal Surgery,
Type___________
□ Abd/Umbil Hernia Repair
□ Amputation
□ AV Fistula Creation
□ AV Graft
□ Aortic Valve Replacement
□ Appendix Removal
□ Breast Surgery
□ Bronchoscopy
□ C-Section
□ CABG (Heart Bypass)
□ Carotid Endarterectomy
□ Carpal Tunnel
□ Cataract
□ Gallbladder Removal
□ Colon Surgery
□ Colostomy
□ Craniotomy (Brain Surgery)
□ Gastric Bypass
□ Hemorrhoid Removal
□ Hip Replacement
□ Inguinal Hernia Repair
Revised 8/2015
□ Knee Arthroscopy
□ Knee Replacement
□ Spine Surgery
□ Lap Band-Gastric
□ Breast Lump Removal
□ Breast Surgery
□ Mitral Valve Replacement
□ Kidney Removal or Transplant
□ Pacemaker
□ Pain Injections
□ Parathyroid Removal
□ Lung Surgery
□ Angioplasty
□ Supra-pubic Catheter
□ Rotator Cuff Repair
□ Uterus and Ovary Removal
□ Uterus Removal only
□ Tonsil Removal
□ Tubal Ligation (Female
Tubes Tied)
□Urinary Incontinence Surgery
□ Vasectomy
□ Anesthesia Problem – NO
□ Breast Disease
□ Breast Cancer
□ Cervical Cancer
□ Diabetes – Gestational
□ Infertility
□ RH Sensitized
□ Uterine Anomaly
Other Issues Not Listed:
□ Anesthesia Problem - YES
□ Cervical Spine Fusion
□ Thoracic Spine Fusion
□ Lumbar Spine Fusion
□ Cervical Spine Laminectomy
□ Thoracic Spine
Laminectomy
□ Lumbar Spine Laminectomy
□ Kyphoplasty
□ Surgical Complications NO
□ Surgical Complications YES
□ Post-op delirium
Other Surgeries Not Listed:
Do you have a Family History of any of the following? (Please √):
□ Unknown □ Adopted
□ Alcoholism
□ Anemia
□ Arthritis
□ Anesthetic Complication
□ Anxiety
□ Asthma
□ Birth Defects
□ Bleeding Disorder
□ Breast Cancer
□ Colon Cancer
□ Depression
□ Diabetes
□ Heart Disease
□ Hypertension
□ High Cholesterol
□ Kidney Disease
□ Lung Disease
□ Migraines
□ Osteoporosis
□ Seizures
□ Severe Allergies
□ Stroke
□ Thyroid Disease
□ Other Cancer
□ Angina
□ Cervical Cancer
□ Coronary Heart Disease<55
□ Coronary Heart Disease<65
□ Colon Cancer – Father
□ Colon Cancer - Mother
□ Growth/Development
□ Lung Cancer
□ Melanoma
□ Ovarian Cancer
□ Uterine Cancer
□ Weight Disorder
□ Other Medical Problems
□ Endometriosis
Other Issues Not Listed:
Please check the boxes that apply to your Social situation: (Please √ /fill in/circle):
□ Single
□ Married
□ Divorced
□ Widowed/Widower
□ Employed
□ Retired
□ Unemployed
□ Disabled
□ Occupation_____________
□ Live in Care Facility
□ Live with ______________
Children? At home? ________
Grown? ___________
Religious Preference affecting care:
(list)________________
Do you feel safe at home? _________
Medical Risk Factors (Please √ your answers to the following):
Tobacco Use:
□ Current
Year Started:
Cigarettes □ Yes □ No
Amount Pk/Day:
Cigars □ Yes □ No
Amount #/Wk:
Smokeless □ Yes □ No
Amount Per Day:
□ Quit
Year Quit:
Pack/Years:
□ Never
Passive Smoke Exposure:
□ Yes
□ No
Illegal Drug Use:
□ Yes
□ No
HIV High Risk Behavior:
□ Yes
□ No
Caffeine Use (drinks/day):
Alcohol Use: □ Yes
□ No
Type:
Amount/day:
Exercise:
Times/week _____________
Seatbelt Use:
□ 0% □ 25% □ 50% □ 75% □100%
Sun Exposure: (circle one)
Freq: Occas Rarely Remote
Have you ever had:
Colonoscopy □ Yes □ No
If yes, when? _____________
(For women)
Mammogram □ Yes □ No
If yes, when? _____________
Pap Smear □ Yes □ No
If yes, when? _____________
Review of Systems (Please √ only if you are currently suffering from any of the following):
General
□ Loss of appetite
□ Chills
□ Dizziness
□ Fatigue
□ Fever
□ Continued Fever
□ Headache
□ Feeling Ill
□ Sweats
□ Night sweats
□ Sleep disturbance
□ Weight loss
Eyes
□ Blurring of Vision
□ Double Vision
□ Eye Irritation
□ Discharge
□ Vision Loss
□ Eye Pain
□ Eye swelling
□ Droopy eyelid
□ Sensitivity to light
□ Redness
□ Itching
Ear/Nose/Throat
□ Earache
□ Ear discharge
□ Ringing in the ears
□ Decreased Hearing
□ Nasal Congestion
□ Nosebleeds
□ Runny nose
□ Hoarseness
□ Difficulty swallowing
□ Dry mouth
□ Bleeding gums
□ Swollen glands
Cardiovascular
□ Chest pain
□ Palpitations
□ Feeling faint
□ Trouble breathing with exertion
□ Shortness of breath-lying down
□ Shortness of breath at night
□ Peripheral edema
□ Elevated blood pressure
□ Decreased heart rate
Respiratory/Breast
□ Cough
□ Difficulty breathing
□ Shortness of breath
□ Excessive sputum
□ Coughing up blood
□ Wheezing
□ Chest pain
□ Breast changes
□ Breast lumps
□ Nipple discharge
Gastrointestinal
□ Nausea
□ Vomiting
□ Cramps
□ Diarrhea
□ Bloody diarrhea
□ Watery diarrhea
□ Constipation
□ Change in bowel habits
□ Abdominal pain
□ Blood in stool
□ Black or tarry stool
□ Jaundice
□ Heart burn
□ Urge to defecate
Genitourinary
□ Urinary incontinence
□ Pain with urination
□ Burning with urination
□ Urinary frequency
□ Urinary hesitancy
□ Urinary urgency
□ Urinary urgency at night
□ Incomplete emptying
□ Blood in urine
□ Absence of menstrual period
□ Heavy menstrual period
□ Prolonged menstrual period
□ Pelvic pain
□ Abnormal vaginal bleeding
□ Painful intercourse
□ Vaginal discharge
□ Vaginal sores
□ Genital burning
□ Genital itching
□ Genital warts
□ Anal discharge
□ Anal sores
□ Anal warts
Musculoskeletal
□ Back pain
□ Joint Pain
□ Leg pain
□ Other pain-see comment
□ Joint swelling
□ Body aches
□ Muscle aches
□ Muscle cramps
□ Muscle weakness
□ Stiffness
□ Recent Injury
Dermatologic
□ Rash
□ Hives
□ Redness
□ Itching
□ Dryness
□ Suspicious lesions
□ Athlete’s foot
□ Rash on palms
□ Rash on bottom of feet
Neurologic
□ Muscle impairment
□ Weakness
□ Numbness and tingling
□ Seizures
□ Slurred speech
□ Feeling faint
□ Tremors
□ Vertigo
□ Paralysis on both sides
Psychiatric
□ Depression
□ Anxiety
□ Memory loss
□ Mental disturbance
□ Suicidal ideation
□ Homicidal ideation
□ Hallucinations
□ Paranoia
□ Feeling stressed
□ Hearing voices
Endocrine
□ Cold intolerance
□ Heat Intolerance
□ Excessive thirst
□ Excessive Hunger
□ Excessive urination
□ Weight loss
□ Weight gain
Hematology
□ Abnormal bruising
□ Bleeding
□ Enlarged lymph nodes
Allergy
□ Hives
□ Swelling
□ Hay fever
□ Persistent infection
□ HIV/STI exposure
□ Other Issues Not Listed: