Download Patient History Form

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
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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:
___
___
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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
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