OOA Medical History Questionnaire

OOA Medical History Questionnaire

ACCT#: DATE:

NAME:

AGE:________ WEIGHT:_________ HEIGHT:__________

DOB:

What are we seeing you for today: ___________________________________________________

YOUR REFFERING PHYSICIAN:

PHARMACY NAME

Location________________________ Phone #

Do give our office consent to import your medications from your pharmacy listed above? Yes No

YOUR CURRENT SYMPTOMS: (Please answer yes or no)

REVIEW OF SYSTEMS

General

Yes No TROUBLE SLEEPING

Yes No FEVERS

Yes No FATIGUE

Skin

Yes No ENLARGING SKIN ULCERS OR LESIONS

Ears

Yes No RECURRENT EAR INFECTIONS

Yes No EAR PAIN

Yes No TV TURNED UP LOUDER THAN OTHERS

Yes No HEARING LOSS

Yes No PROBLEMS HEARING IN CROWDS

Yes No RINGING IN THE EARS

Eyes

Yes No DOUBLE VISION OR VISION CHANGES

Yes No EYE DRYNESS

Nose

Yes No RECURRENT SINUS INFECTIONS

Yes No SNORING

Yes No NASAL CONGESTION / STUFFINESS

Yes No NASAL ITCHING, SNEEZING

Mouth/Throat

Yes No ORAL SORES

Yes No RECURRENT SORE THROAT

Yes No HOARSENESS

Respiratory

Yes No COUGH

Yes No SHORTNESS OF BREATH

Cardiovascular

Yes No ABNORMAL HEART RHYTHM

Yes No CHEST PAIN WITH EXERTION

Yes No ANTIBIOTICS BEFORE DENTAL PROCEDURES

Neuro

Yes No HEADACHES OR MIGRAINE

Yes No WEAKNESS OR NUMBNESS

Gastrointestinal

Yes No DIFFICULTY SWALLOWING

Yes No HEARTBURN OR ACID REFLUX

Yes No REGURGITATING FOOD

Heme

Yes No ABNORMAL BLEEDING

Yes No GENERALIZED WEAKNESS

Endocrine

Yes No HAIR THINNING OR MORE COARSE

Yes No WEIGHT GAIN OR LOSS

Genitoruninary

Yes No FREQUENT URINATION

Yes No DIFFICULTY URINATING

Yes No STRESS INCONTINANCE

Neck

Yes No NECK MASS

Yes No NECK PAIN

Are you currently receiving Home healthcare? Yes No

PREVIOUS SURGERY: (Please circle all that apply)

Ear Surgery, Tonsils/Adenoids, Gallbladder, Heart, Hernia,

Hysterectomy, Colon, Lung, Back, Urinary/Kidney

Other:

YOUR PAST MEDICAL CONDITIONS: (Please answer yes or no)

Yes No KNOWN HEARING LOSS

Yes No DEPRESSION

Yes No HISTORY OF STROKE

Yes No GASTROESOPHAGEAL REFLUX

Yes No HEART DISEASE

Yes No ASTHMA

Yes No CHRONIC LUNG DISEASE

Yes No NASAL ALLERGY

Yes No HIGH BLOOD PRESSURE

Yes No HISTORY OF HEART ATTACK

Yes No HISTORY OF HEART DISEASE

Yes No MIGRAINE

Yes No HIV/ AIDS

Yes No CANCER

Yes No OBSTRUCTIVE SLEEP APNEA

Yes No BLOOD DISEASE / ANEMIA

Yes No HISTORY OF THYROID DISEASE

Yes No DIABETES TYPE I? TYPE II?

Yes No KIDNEY DISEASE

Yes No PROSTATE PROBLEMS

Yes No HISTORY OF SKIN CANCER

PLEASE LIST ANY MEDICAL PROBLEMS,

HOSPITALIZATIONS, ILLNESSES NOT LISTED ABOVE:

ALLERGIES TO DRUGS OR MEDICATIONS: (Please List)

PRESENT MEDICATIONS:

Medication Dosage Frequency

_______________________ ____________ ________

_______________________ ____________ ________

_______________________ ____________ ________

_______________________ ____________ ________

_______________________ ____________ ________

_______________________ ____________ ________

SOCIAL HISTORY, DO YOU: (Please answer yes or no)

Yes No DRINK CAFFEINE

Estimate Caffeine Consumption

Yes No SMOKE CIGARETTES Packs Per Day?

Yes No SMOKE CIGARS

Yes No CHEW TOBACCO, DIP

Yes No DRINK ALCOHOL REGULARLY

Estimate Alcohol Consumption

PEDIATRIC SOCIAL HISTORY:

Yes No ATTENDS DAYCARE

Yes No EXPOSED TO TOBACCO SMOKE

FAMILY HISTORY: (Please answer yes or no)

Yes No ALLERGIES

Yes No ASTHMA

Yes No HEARING LOSS

Yes No CANCER

Yes No OTHER:___________________________________