Return to Web Site                 Kentuckiana Ear, Nose & Throat, PSC
Please Print                                      MEDICAL HISTORY                     DOB _________
 
Patient Name____________________________________ Appointment Date___________
1. Please state reason for your visit specifically ___________________________________
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2. If your reason involves an injury or injuries, please describe nature and give dates ______
________________________________________________________________________
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3. Are you currently under a doctor's care?         Yes       No
          Doctor's Name __________________________________ Phone ______________
          Address ___________________________________________________________
          Second Doctor __________________________________ Phone ______________
          Address ___________________________________________________________
4. Do you have any allergies to medications?     Yes      No               List:________________
________________________________________________________________________
5. Do you have a history of the following:
              Nasal Allergy                       Yes     No            Chest Pain                             Yes     No
Post-nasal Discharge Yes  No High Blood Pressure Yes  No
Sinus Infection(s) Yes  No Stroke Yes  No
Nose Bleeds Yes  No Diabetes Yes  No
Headaches Yes  No Ulcers Yes  No
Dizziness Yes  No Other Stomach Disease Yes  No
Tinnitus (ringing in ear) Yes  No Anemia Yes  No
Hearing Loss Yes  No Visual Problems Yes  No
Difficulty Breathing Yes  No Glaucoma Yes  No
Difficulty Swallowing Yes  No Thyroid Disease Yes  No
Asthma Yes  No Hepatitis (Liver) Yes  No
Hayfever Yes  No Kidney Disease Yes  No
Tuberculosis Yes  No Convulsive Disorder Yes  No
Lung Disease Yes  No Positive HIV Testing Yes  No
Heart Trouble Yes  No Exposure to HIV Yes  No
Comments _______________________________________________________________
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6. Do you drink alcohol?               Yes      No      Frequency / Amount ___________________
7. Tobacco use:      Current:        Yes      No       #pack(s) per day_______ #years_________
8. Any history of alcohol or drug dependency?            Yes    No

PLEASE Continue with Page 2 

 

Medical History Page 2
Patient Name_________________________________ Appointment Date___________
  
9. List all of the medications you are taking and the dosage you take (including over-the-counter medications such as aspirin, birth control pills, etc.
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10. List all previous surgeries or major illnesses along with appropriate dates. _________
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11. Have you ever had a reaction to anesthetic including injectable anesthetic?
    Yes   No __________
12. Do you have a history of increased bleeding tendency? Yes   No __________
13. Have you ever had a blood transfusion? Yes   No __________
14. Have you been treated for any mental or emotional disorders?  Yes   No __________
15. Do you have a history of scarring?  Yes   No __________
            Where? _________________________________________________________
  
16. Family History
             Have any members of your family had the following?
             Allergies                        Yes      No   __________________________________
             Bleeding Problems       Yes      No   __________________________________
             Cancer                           Yes      No  __________________________________
             Diabetes                        Yes      No  __________________________________
             Heart Disease               Yes      No  __________________________________
17. (For Women) Is there ANY POSSIBILITY you are pregnant?          Yes    No
              Last Menstrual Period  _____________________________________
18. Please list any other information you think important to your medical care.
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Signature of Patient, Parent or Guardian ________________________ Date_________
Doctor Signature__________________________________________ Nurse_________