Kentucky ear, nose and throat patient health history

Kentucky Ear, Nose and Throat Patient Health History
Name:_______________________________ Date of Birth:__________ Date:_________
This section for office use only
Vital Signs: Height:___ft____in Weight:_______ Temp:_______ Pulse:_______ BP ____/____(Adults)

What is the main reason you are being seen at KY Ear, Nose and Throat
Have you or any family member ever been seen at our office before? Yes Name:_________________________

Have you/the patient been diagnosed with any of the following? Check all that apply. 2. TOBACCO USE: □ None □ Quit (date) __________ Stil use: □ Cigarettes □ Smokeless/Chew □ Cigars □ Pipe
Check the amount of tobacco you use(d) each day.
How many years did/have you smoked? ____________ 3. Are you/the patient exposed to second hand smoke? □ Yes □ No
4. ALCOHOL USE: □ None (A drink is 1 shot of liquor, 1 glass of wine, or 1 bottle/can of beer.)
□ Less than 1 drink/month □ 1-15 drinks/month □ 4-14 drinks/week □ More than 2 drinks/day
5. Will you/the patient accept transfusion of blood products if necessary?
6. Does the patient attend daycare? □ Yes □ No
7. HOME LIVING SITUATION: Check all that apply.
□ Alone
□ With mother □ With father □ With spouse □ With siblings □ With children □ In nursing home □ In assisted living □ In foster care □ With significant other 8. FAMILY HISTORY: Check which family members have had the following:


9. REVIEW OF SYSTEMS: Check any symptoms that you /the patient have now or have recently had.
10. ALLERGIES: Are you allergic to any of the following? Check all that apply.
□ Latex
What happens when you take this medication? □ Itching □ Rash □ Nausea □ Shortness of Breath □ Anaphylaxis □ Itching □ Rash □ Nausea □ Shortness of Breath □ Anaphylaxis □ Itching □ Rash □ Nausea □ Shortness of Breath □ Anaphylaxis □ Itching □ Rash □ Nausea □ Shortness of Breath □ Anaphylaxis 12. CURRENT MEDICATIONS: □ NONE
10 Nasal Spray: □ None □ Astelin □ Flonase □ Nasonex □ Nasocort AQ □ Rhinocort Aqua □ Afrin
13. PAST SURGICAL HISTORY: (Include all operations that you have had)
14. OCCUPATION:________________________________________ □ Retired
Your pharmacy is? _________________________
Notes: ______________________________________ Address: _________________________________ ____________________________________________ Phone number: ____________________________ ____________________________________________ This form was completed by: ___________________________________________ Date: ______________________ Relationship to patient: □ Self □ Mother □ Father □ Daughter □ Son □ Other (specify)______________________


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