Download Medical History Questionnaire / ENT

Medical History Questionnaire / ENT
List reason(s) for visit and duration of problem:
Past Medical History
Allergies:
Current prescription medications:
1.
4.
7.
2.
5.
8.
3.
6.
9.
Over-the-counter-medications:
Check any illnesses or condition you have had:
Diabetes
Lung disease/Asthma
Heart disease
Tuberculosis
Kidney disease
Stomach ulcers
High blood pressure
Bleeding problems
Stroke
Seizures
Hepatitis
Blood clots
Other
Hospitalizations: (list problem(s) and year, not including surgeries)
Surgeries: (list all operations and the year performed)
Social History
Marital Status [circle one]: S
Do you smoke?
Yes
M
D
W
Occupation:
If yes, number of years:
No
How many packs per day:
I have never used Illicit drugs. |
Do you drink alcohol now?
S
Quit
Quit date:
/
/
I have | Specify:
Yes
How many beers/drinks per day
No
Quit → Quit date:
/
/
Family History
Serious illnesses/cancer:
Relationship:
Serious illnesses/cancer:
Relationship:
Other:
MAGAN MEDICAL CLINIC
420 W. Rowland St., Covina CA 91723
Medical History Questionnaire_ENT
Page 1 of 2
*mmc*
*395*
APPT. LABEL (REQUIRED ON PAGE 1 ONLY)
Rev [07/2010]
Form 395
Medical History Questionnaire
SYSTEM REVIEW: Check all symptoms that you have had in last 3 months. If not applicable, please
check N/A.
General Health:
Unexplained Weight loss
Appetite change
Fever
Chills
N/A
Eyes:
Change of vision
Double vision
Pain
Ears, Nose, Mouth, Throat (problems other than current visit):
Hearing loss
Nasal discharge
Ear ringing
Sneezing
Ear ache
Stuffy nose
Ear drainage
Nose bleed
Dizziness
Heart, Veins, Arteries (Cardiovascular):
Chest pain
N/A
Irregular heartbeat
Stomach, Intestines (Gastrointestinal):
Indigestion / heartburn
Abdominal pain
Nausea/vomiting
N/A
Skin (Integumentary):
New skin growths
Rash
Psychiatric:
Insomnia
Depression
N/A
Anxiety
N/A
Difficulty chewing
Difficulty swallowing
Pain with swallowing
Sore throat
Facial pain/paralysis
Discharge
Itching
N/A
Hoarseness
Lump in neck
Mouth growth/ulcer/bleed
N/A
Respiratory:
Wheezing
Shortness of breath
Cough
N/A
Coughing up blood
Bones, Joints, Muscles (Musculoskeletal):
Neck pain
Muscle spasms
Back pain
N/A
Neurological:
Headaches
Blackouts
Seizures
Paralysis
Hematologic:
Bleeding problems
Easy bruising
Tingling/numbness of face
N/A
N/A
Discussions:
Patient Signature
Date
MAGAN MEDICAL CLINIC
420 W. Rowland St., Covina CA 91723
Medical History Questionnaire_ENT
Page 2 of 2
APPT. LABEL (REQUIRED ON PAGE 1 ONLY)