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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)