Otology/ and Balance Center

Patient Name: ______Date of Birth: ______

Date of Visit:______Height:______Weight: ______

Pharmacy Name:______City:______

Referring Provider: ______( first name, last name and location)

Primary Care Physician: ______( first name, last name and location)

Are there any other healthcare providers who should receive a copy of your records?______

Your current occupation: ______

Reason for today’s visit: ______

______

Approximate date symptoms began: ______

DRUG ALLERGIES: Please list drug allergies with reaction to each.

______

NO DRUG ALLERGIES : ______

MEDICATIONS: Please list all medications you are currently taking, include over the counter medications. Name of Medication Dosage

( continue on back if needed)

Otology/Hearing and Balance Center

Patient Name: ______Date of Birth: ______

Have you had a recent CAT scan or MRI? ______

PAST MEDICAL HISTORY: Have you ever had any of the following conditions? Circle if YES. Anemia Anxiety Arthritis Asthma Cancer Heart Failure COPD Coronary Artery Disease Depression Diabetes Emphysema GERD Graves Disease Headaches Hypothyroidism Hypertension Hyperthyroidism Kidney Disease Heart Murmur Migraines Seizures Sleep Apnea Bleeding Disorders Ulcers High Cholesterol Snoring Otosclerosis Other health conditions:______

Please list any prior surgical procedures: Past Surgery/ Date of Surgery 1. 2. 3. 4. 5. 6. 7.

FAMILY HISTORY: Does anyone in your family have the following ? If so, please check . Condition Mother Father Sister Brother Child

Hearing loss Migraine Otosclerosis Syndromes Please circle the appropriate response: Tobacco use: yes no Quit Date:______

Otology/Hearing and Balance Center

Alcohol: yes no Non prescription drug use: yes no

Have you traveled outside of the U.S. in the last 21 days? If so, where? ______

Do you currently have any pending legal cases regarding your condition? ______

Please circle any that you have experienced in the past 4 weeks. CONSTITUTION HEMATOLOGIC GU Activity change Enlarged lymph nodes Difficulty urinating Appetite change Bruises easily Urinary urgency Chills Bleeds easily MUSCULAR Excessive sweating CARDIO Joint pain Fatigue Chest pain Back pain Weight change Leg swelling Gait Problem HENT Heart palpitations Joint swelling Congestion NEUROLOGICAL Muscle pain Dental problem Dizziness Drooling Facial asymmetry Neck pain discharge Light headedness Neck stiffness Numbness ENDOCRINE Facial swelling Seizures Cold intolerance Hearing loss Speech difficulty Heat intolerance Mouth sores Fainting Excessive hunger Nosebleeds Tremors Postnasal drip PSYCHIATRIC Excessive thirst Runny nose Agitation Excessive urination Sinus pressure Behavior problems SKIN Sore throat Confusion Color change Ringing in ear Decreased concentration Rash Trouble swallowing Depression Skin wound Voice change Hallucinations ALLERGIES EYES Hyperactivity Environmental allergies Eye discharge Nervous/Anxious Food allergies Eye itching Self-injury Eye pain Suicidal ideas Immunocompromised Eye redness Sleep disturbance Light sensitivity GI Vision change Abdominal distention RESPIRATORY Abdominal pain Apnea Anal bleeding Chest tightness Blood in stool Choking Constipation Cough Diarrhea Shortness of breath Nausea Noisy breathing Rectal pain Wheezing Vomiting