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Transcript
Patient Name: _____________________ Date of Visit______________________ Date of Birth_____________________ Ear Infections Questionnaire History: Select all symptoms that the patient has experienced while having an ear infection. Scale of symptom severity: 5: very severe 4: severe 3: moderate 2: mild 1: very mild Ear Fullness Ear Pain Ear Pressure Ear Discharge/Purulence Drainage Loss of hearing Fever (Acute Only) Dental Pain Ear Drum Rupture Associated Factors Headache Post Nasal Drip Sinus Pressure Upper respiratory infection Runny Nose Cough 1 2 3 4 5 EAR INFECTIONS Six Months One Year How many ear infections has the patient had in the last How many time have antibiotics been used as treatment in the last How many times has the ear drum ruptured in the last ear Infection Questionnaire 9-2010.doc Modified on 10/4/2010 History of Medical Treatment: Decogestants/Mucolytic/Antihistami nes Helped Did not help Helped Did not help Sudafed or similar over the counter medications Robitussin or combination of robitussin Clarinex/Claritin Allegra Zyrtec liq Tanafed DP, DMX, Tussi-12S Other: _________________ Intranasal or Oral Steroids Astepro/Astelin Flonase Nasonex Rhinocort AQ Nasacort AQ Veramyst Other: _________________ Antibiotics How many Days did you take? How many times did you take? Did it help you? Amoxicillin Augmentin Bactrim DS Biaxin Cedax Ceftin Cefzil Omnicef Zithromax Other IV Medications: Allergy History: Symptoms Sneezing Clear Nasal Discharge Milk Allergy Symptoms all-year-round Symptoms are seasonal Spring Yes No Fall EXPOSURE & PERSONAL HISTORY Is the patient exposed to cigarette smoke? Yes No Is the patient enrolled in day care or babysitting? Yes No Is the patient is a child, did the child have any complications at birth? Yes No Did the child have to be exposed to any IV medications? Yes No
