Patient Information Sheet

PATIENT INFORMATION SHEET
Name:	_________________________________________________
Address:	_________________________________________________
E-mail address:	_________________________________________________
DOB:	_________________
Phone numbers:
Home	____________________________
Work	____________________________
Fax	____________________________

Please list the names of your referring physician if applicable, and other physicians whom you would like to receive a report:
____________________________ physician name	____________________________ physician name
____________________________ street address	____________________________ street address
____________________________ city, state, zip code	____________________________ city, state, zip code
____________________________ phone number	____________________________ phone number
____________________________ physician name	____________________________ physician name
____________________________ street address	____________________________ street address
____________________________ city, state, zip code	____________________________ city, state, zip code
____________________________ phone number	____________________________ phone number

Please state the reason for this consultation.

Have you ever had surgery before, including plastic surgery? If so, please list, including (approximate) year-of-surgery.
1.
2.
3.
4.
5.
6.
7.

Have you ever had traumatic injury to your nose (i.e., a broken nose)?
Please list any medical problems for which you have received or are receiving care for.
1.
2.
3.
4.
5.
6.
7.

Do you take any medications? Please list below
1.
2.
3.
4.
5.
6.
7.

Have you ever been hospitalized? _____ Yes _____ No
If yes, please list:

Do you take aspirin, or any products with aspirin in it? _____ Yes _____ No
If so, how much & how often?
Do you have any drug allergies? _____ Yes _____ No
If yes, please list all, and list what your reaction was:

Do you have environmental allergies? _____ Yes _____ No
If yes, have you had allergy shots? _____ Yes _____ No
If yes, did they help? _____ Yes _____ No
If yes, please circle which allergy symptoms you have:
Sneezing
Itchy Nose
Itchy/runny/watery eyes
Itchy throat
Itchy ears
Runny nose

Do you have asthma? _____ Yes _____ No
Do you have migrane headaches? _____ Yes _____ No
Nose and sinus sumptoms: Do you have any of the following symptoms? If yes, please rate on a scale of 1 (mild) to 5 (severe).

Nasal blockage or stuffiness 1 2 3 4 5

Postnasal drip 1 2 3 4 5

Discolored nasal drainage 1 2 3 4 5

Nasal bleeding 1 2 3 4 5

Ear fullness 1 2 3 4 5

Sinus infections 1 2 3 4 5

Sore throat 1 2 3 4 5

Headache or facial pain 1 2 3 4 5

Halitosis (bad breath) 1 2 3 4 5

Snoring 1 2 3 4 5

Cough 1 2 3 4 5

Tooth pain 1 2 3 4 5

MEDICAL HISTORY: We would like to have a thorough knowledge of your medical history. With this in mind, please check "yes" if you have EVER had a problem with any of the areas listed below, and "no" if you have not.

General	yes	no
Arthritis
Asthma
Diabetes
Easy bruising/bleeding
Gastritis/Peptic Ulcer Disease
High blood pressure
Kidney disease
Liver disease/Hepatitis
Lung disease, including pneumonia
Meningitis
Seizures
Tuberculosis
Ulcer, other gastrointestinal disease
Cardiopulmonary
Heart murmur
Palpitations
Chest pain (angina)
Shortness of breath
Wheezing
Chest tightness
Heart arrhythmias
Mitral valve prolapse
Heart attack
Eyes
Recent change in vision
Double vision
Clouded vision
Cataracts
Glaucoma
Endocrine
Heat/cold intolerance
Excessive thirst
Thyroid problems
Psychological
Depression
Other

Do you smoke? __ no __ yes If so, how much?
If you smoked in the past, when did you quit?
Do you drink alcohol? __ no __ yes If so, how much?
FAMILY HISTORY:
Please circle all that apply to your family members.
Allergy
Sinus Disease
Immunodeficiency
Cystic Fibrosis
Bleeding Disorder
Asthma
High Blood Pressure
Heart Disease
Diabetes
Cancer
SOCIAL HISTORY:
Please state your current occupation: ____________________________________
Please state your marital status: _______________
Have you had any recent changes in your home or work environment? Please describe.

Email: beckermailbox@aol.com