Health History Form

Patient Name

DOB

Do you have or have you ever had the following (Mark all that apply):

ENT History

Other

ENT Family History

ENT Pediatric History

Does anyone in your family have below:

None

Otitis Media (Middle Ear Infection)

Sinusitis

None

Cleft Lip

Cleft Palate

ENT Surgical History

Other

Past Surgeries

Have you had any of he following surgeries or procedures?

Other

Past Medical Conditions

Other

Social History

Smoking Habits

What is your smoking status? (QM402,QM226)

Unknown if ever smoked

Current smoker-Cigarettes

Current every day smoker

Former Smoker

Current smoker – Tobacco

Never smoker

Cigar smoker

Alcohol and Drug Use

How many times in the past year you had 5 or more drinks in a day for men, or 4 or more drinks in a day for women or any adult older than 65? (QM431) Enter Number

Do you consume alcohol (EtOH or grain alcohol)?

Y N

Recreational Drug Use?

Y N

Driving Status

Drive in the Daytime?

Y N

Drive at Night?

Y N

Exercise Status

How often do you exercise?

Caffeine Usage

Occupation

Do you drink caffeinated drinks?

Y N

What is your occupation and workplace?

If so, How many per day?

Residence Status

What is your place of residence?

Do you feel safe at your place of residence?

Y N

Medication List

Add new row

Your information will be encrypted.