Teen - Personal Medical History

Please correct the errors described below.

Have you ever been diagnosed with or had to take medication for any of the following conditions?

Please give details for all "yes" responses.

Please list all medications you take on a regular basis. (Include inhalers and diabetes medicines, if applicable.)

Add new medication

In association with the specific Ear, Nose and Throat problem or problems that bring you to our office today, have you noticed any of the following?

EARS

NOSE/SINUSES

THROAT

NECK

GENERAL

KIDNEY/BLADDER

EYES

MUSCLE/JOINTS

HEART

SKIN

LUNGS

NEUROLOGIC

GASTROINTESTINAL

PSYCHOSOCIAL

HORMONAL

BLOOD

Your information will be encrypted.

Loading...