Ohio Ear Institute, LLC

 

450 Alkyre Run Rd., Suite #300
Westerville, OH 43082

          

            

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:_________________________________________

 

___________________________________________________________________________________

 

___________________________________________________________________________________

 

SURGERIES/HOSPITALIZATIONS

YEAR

 

 

 

 

 

 

   

 

MEDICATIONS (List Name, dosage and frequency)

1.

5.

9.

2.

6.

10.

3.

7.

11.

4.

8.

12.


DRUG ALLERGIES :________________________________________________________________

 

FAMILY HISTORY

(List family member and history of hearing loss, dizziness, migraine or acoustic tumor)

 

 

 

 

 

 

 

   

 

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

 

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

 

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

 

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

 

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

 

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:____________