Ohio Ear Institute, LLC
450 Alkyre Run Rd., Suite #300 |
PATIENT HEALTH HISTORY
Patient Name:__________________________________________Date of Birth:__________________
CHIEF CONCERN
Reason for today's visit:_______________________________________________________________
PAST MEDICAL HISTORY
Please list any prior major illnesses and/or injuries:_________________________________________
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SURGERIES/HOSPITALIZATIONS |
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MEDICATIONS (List Name, dosage and frequency)
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5. |
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11. |
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12. |
DRUG ALLERGIES :________________________________________________________________
FAMILY HISTORY
(List family member and history of hearing loss, dizziness, migraine or acoustic tumor)
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SOCIAL HISTORY
Occupation:_________________________________________________________________________
History of smoking?: No ____ Yes ____ If yes, what type and for how long?____________________
History of alcohol use: No_____ Yes____ How often?______________________________________
REVIEW OF SYSTEMS (Please circle all items that you have had problems with)
CONSTITUTIONAL Fever Weight Loss Excessive Fatigue Night Sweats
EYES Wear glasses/contacts Infections Injury Glaucoma Cataract
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RESPIRATORY Asthma Chronic Cough Emphysema Shortness of Breath Bronchitis Pneumonia Lung Cancer Bloody Sputum |
NEUROLOGICAL Fainting Spells or Blackouts Seizures Migraine Headaches Problems with Memory Disorientation Difficulty with Speech Inability to Concentrate Double or Blurred Vision Face Weakness Coordination in Arms and/or Legs
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EAR, NOSE & MOUTH Wear Hearing Aid (Date of last exam_____) Hearing Loss Ear Pain Ear Infection Ringing in the Ear(s): Left___ Right___ Both___ Balance Disturbance: Vertigo____ Spinning____ Unsteadiness_____ Floating Sensation____ Lightheadedness____ Nosebleeds Nasal Congestion Nasal Drainage Inability to Smell Sinus Problem Sinus Headaches Sore Throat Mouth Sores
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GASTROINTESTINAL Indigestion and Pain with Eating Nausea Vomiting Blood in Vomit Liver Disease Jaundice Abdominal Pain Change in Bowel Habits Ulcers or Gastritis Colon Cancer
GENITOURINARY Urinary Tract Infection Painful Urination Blood in your Urine Difficulty Starting/Stopping Stream Incontinence Kidney Stones Prostate Cancer Endometriosis Uterine or Cervical Cance
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ENDOCRINE Diabetes Thyroid Disease Increased Appetite Excessive Thirst or Urination Hormone Problems
HEMATOLOGIC Anemia Hemophilia Bleeding Tendency Persistent Swollen Glands or Lymph Nodes Blood Transfusion Date:_________
SKIN Skin Disease Skin Cancer Breast Pain, Tenderness or Swelling Nipple Discharge |
CARDIOVASCULAR Chest pain or angina High Blood Pressure Irregular Pulse Heart Murmur High Cholesterol Swelling in Feet and Hands Leg Pain/Cramping While Walking |
MUSCULOSKELETAL Broken Bones Arm or Leg Weakness Back Pain Arm or Leg Pain Joint pain or Swelling Arthritis
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ALLERGIC: Food Allergies Inhalant (nasal) Allergies Immunologic Disorder(s):__________
PSYCHIATRIC Anxiety/Depression Other:____________________ |
The above information is accurate to the best of my knowledge:
Patient (or Guardian) Signature:_____________________________________________ Date:____________
The above information has been reviewed with the patient and is deemed correct:
Physician:_______________________________________________________________ Date:____________