160 East Lake Howard Drive Winter Haven, Florida 33881 THE Sebring Lakeland Lake Wales Haines City Clermont Ocoee BARRANCO CLI NIC Phone (863) 299-1251 Fax (863) 299-7666

MEDICAL HISTORY

PATIENT NAME______Today’s Date:______/______/______

Date of Birth:_____/______/______Daytime Phone Number:____/_____/______Height.:______Weight:______Sex: M F

Referred By:______Phone Number: ____/______/______Primary Care Doctor: ______PATIENT REVIEW OF SYSTEMS FAMILYFAMILY HISTORYHISTORY

PAST MEDICAL HISTORY Have you recently had or PLEASE CHECK ANY THAT APPLY or UNKNOWN_____ do you have any problem with: PARENTAL SIBLING

YES NO YES NO Heart Disease Asthma EARS Hypertension Hayfever (Allergic Rhinitis) Hearing Loss Diabetes Allergy Injections Pain Hearing Loss History of Allergy Testing Pressure Asthma Hypertension/Heart Disease Ringing Cancer Shortness of Breath (SOB) Vertigo or Dizziness Bleeding Disorders Wheezing Noise Exposure Allergies Diabetes Freq. Inf. SOCIAL HISTORY Eyes Problems or Twitching Discharge

Facial Numbness Dysequilibrium Do you Smoke? _____No ______Yes Headaches NOSE If yes, #______packs/day for ______years Arm/Leg Weakness Trauma Neck Pain Are you a Former Smoker? ___ Yes Surgery Quit # of years ______Back Ache Obstruction Cancer Coffee? ______No ______Yes #_____cups per day Discharge Weight Loss Alcohol? ______No ______Yes # per day______Post Nasal Drip (PND)

Abdominal Pain Epistaxis (Nosebleed) Do you use Recreational Drugs? _____No _____Yes Acid or GI Reflux Snoring Are you: _____Married _____ Single _____Divorced Anemia/Bleeding Disorders Changes in Sense of Thyroid Disease Smell ARE YOU ALLERGIC TO ANY MEDICATIONS? PLEASE LIST BELOW. Sleep Apnea THROAT/LARYNX

Fallen in last Year Difficulty Swallowing 1.

If yes, Fallen 2 or more times Frequent Infections or with injury Soreness 2. Pneumonia Vaccine (ever) Frequent Clearing 3. Influenza Vaccine Voice Changes Skin Disease 4. Spitting Up Blood 5. Office Use Only: Reviewed and entered by: Changes in Sense of Taste

______Date: ____/____/_____ PLEASE USE THE BACK OF THIS SHEET TO RECORD YOUR CURRENT MEDICATIONS, PAST SURGICAL HISTORY AND ANY ADDITIONAL MEDICAL HISTORY .

PATIENT NAME:______Today’s Date:______

PLEASE LIST ALL MEDICATIONS List all tablets, patches, drops, ointments, injections, etc. Include prescription, over-the-counter, herbal, vitamin, and diet supplement products. Also list any medicine you take only on occasion.

MEDICATION WHAT IS THE DIAGNOSIS FOR THIS MEDICATION ? 1.

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If you need additional space talk with Medical Assistant once you have been called back Check here if additional pages of medicine to a room. list attached [ ]

HAVE YOU HAD? YES NO PAST SURGICAL HISTORY HIP REPLACEMENT KNEE REPLACEMENT

OPERATION DATE OPERATION DATE

1. 5.

2. 6.

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Please use the space below for any additional medical history not included on the front

Office Use Only: Reviewed and entered by: ______Date: ____/____/_____