Health History Form

Please correct the errors described below.

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

ENT History

ENT Family History

ENT Pediatric History

Does anyone in your family have below:

ENT Surgical History

Past Surgeries

Have you had any of he following surgeries or procedures?

Past Medical Conditions

Social History

Smoking Habits

Alcohol and Drug Use

Driving Status

Exercise Status

Caffeine Usage


Residence Status

Medication List

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