Patient History Form

Patient:

Date:

Reason for visit:

ENT History

Ear

Pain

Discharge

Hearing loss

“Noise in ear/ head”

“Balance problem”

Other:

Nose/Sinus

Obstruction

Nasal discharge

Post- nasal discharge

Facial/ nasal pain

Decreased smell/ taste

Bleeding

Other:

Throat

Sore throat/ “burning throat”

Hoarseness / vocal change

Swallowing problem

Cough

Other:

Allergy

Inhalant

Medication

Food

Insect bites/ stings

“Sensitivity” to odors, fumes, weather conditions

Prior allergy test

Prior allergy desensitization /”shots”/ “sublingual

If "Inhalant", please provide the information needed below:

Symptoms:

Time of year:

”Triggers”:

If "Prior allergy test", please provide the information needed below:

Where:

When:

Other:

Snoring/ Sleep Apnea

“Breatholding/ gasping” during sleep

Daytime fatigue/ daytime naps

Restless sleep / morning headaches

Other:

Medical History

Hospitalizations

Add hospitalizations

Surgeries

Add surgeries

Medications Taken

Add medications taken

Family Medical History

Add family medical history

Social History

Tobacco

Cigarette

Cigar

per day

per year

Alcohol

Wine

Beer or mixed drinks

per day

per year

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