ENT Patient History Form

Patient's Name

Date of Birth

Reason for visit

When did this problem begin?

Is there anything that makes the problems better or worse?

How often has the problem occurred in the past six months?

What providers have you seen for this problem?

What treatments have you had for this problem?

(Allergy testing) If so, when and where?

(CT scan sinuses) If so, when and where?

(CT scan chest) If so, when and where?

(Pulmonary Function Testing) If so, when and where?

(MRI) If so, when and where?

(EGD (Upper endoscopy)) If so, when and where?

(Bravo, impedance..)If so, when and where?

(Barium Swallow Study) If so, when and where?

(Esophageal Manometry) If so, when and where?

(Colonoscopy) If so, when and where?

Primary Care Provider

Preferred Pharmacy

Current medications:

Add Medications

Allergies to medications:

Add Allergies

Allergies to other substances (food, animals, pollens, metals, chemicals, latex, adhesives)

Date (mm/dd/yyyy) received the following vaccines

Pneumococcal

Flu vaccine (most recent)

COVID vaccine #1

COVID vaccine #2

COVID vaccine booster

Type of COVID vaccine received

Social History

Do you smoke tobacco?

Yes No

If so, how much

Are you a former tobacco smoker?

Yes No

If so, how much did you smoke, for how many years, and when did you quit?

Do you use chewing tobacco?

Yes No

Did you previously use chewing tobacco?

Yes No

If so, for how many years and when did you quit?

Do you use marijuana?

Yes No

If so, in what form(s) and how often?

Second-hand smoke exposure as a child?

Yes No

Currently?

Illicit drug use currently?

Yes No

If so, what substances and frequency.

Previous illicit drug use?

Yes No

If so, what substances, for how long, and when did you quit?

Do you drink alcohol?

Yes No

If so, how many drinks per week on average?

If no longer drinking alcohol, did you previously?

Yes No

If so, how many drinks per week on average, for how many years, and when did you quit?

Hospitalizations:

Add Hospitalization

Surgeries:

Add Surgeries

Medical Condition:

(For additional Condition Please click "Add condition Below")

Add Condition

Other mood disorder, Please list

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Patient Name / Signature

Date

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ENT Patient History Form

Current medications:

Allergies to medications:

Social History

Hospitalizations:

Surgeries:

Medical Condition:

SouthDenver ENT & Allergy