EAR, NOSE, THROAT & AUDIOLOGY ASSOC OF THE CAROLINAS
NEW PATIENT (ADULT)
Name ______Today’s Date ______Age ______
Family Physician ______
Reason for your visit? ______
______PLEASE ANSWER ALL QUESTIONS BELOW______
PAST MEDICAL HISTORY:
Liver disease Y N Diabetes Y N Thyroid Disease Y N
Heart Disease Y N High Blood Pressure Y N Asthma Y N
Infectious Diseases Y N Emphysema Y N Bleeding Disorders Y N
Seizures Y N Infectious Diseases Y N Cancer Y N
PAST SURGICAL HISTORY: (List all surgeries you’ve had)
______FAMILY HISTORY: (Blood relatives only, please circle Yes or No and specify relationship)
Cancer Y N______Diabetes Y N______Heart Disease Y N______
Bleeding Y N______Hearing Loss Y N______Anesthesia Problems Y N______
SOCIAL HISTORY:
Cig smoking _____packs/day for ____ years. Alcohol use ____ Daily, ____ Weekly, ____ Seldom, _____ Never
MEDICATIONS: List all current medications, over the counter and herbal medicines. If list too extensive we will photocopy.
______
______
______
MEDICATION ALLERGIES:
______
(Additional questions on next page)
REVIEW OF SYSTEMS:
Please circle any of the following problems that apply to you.
GENERAL HEMATOLOGIC/LYMPHATIC
Weight loss or gain Swollen glands
Fatigue Bruise easily
Poor appetite Spontaneous bleeding
Fever Blood clotting
RESPIRATORY CARDIAC
Shortness of breath Chest pain
Frequent cough Murmur
Coughing blood Heart disease
Wheezing Heart Attack
NEUROLOGIC INTEGUMENTARY
Balance problem / Vertigo Rashes
Weakness Eczema
Sleepiness Hives
EYES GASTROINTESTINAL
Vision Problems Abdominal Pain Bloody Stool
Watery eyes Nausea/Vomiting Jaundice
Eye discharge Heart burn Swallowing difficulty
EAR NOSE - SINUS/ALLERGY
Ringing in ears Sneezing Itchy eyes or nose Decreased hearing Runny nose Nasal stuffiness
Ear drainage Sniffing Sinus problems
Ear pain Nose bleeds
Dizziness
THROAT SLEEP PATTERN
Sore throats Restless sleep Snoring
Hoarseness Gasping for air Daytime fatigue
Morning headaches Sleepiness in the Daytime
PHYSICAL EXAMINATON: FOR OFFICE USE ONLY (Please do not write below)
Vital Signs BP ______P______T______HT______WT______
FINDINGS:
PLAN: