Patient Infromation | Personal Health History Form

This form will be part of your medical record. Upon completion, please sign the last page, All history is held strictly confidential and is released with your written permssion.

No PrimaryPhysician How did you hear of our clinic (check all that apply)       In your own words what is the reason for your own visit Internet Search Previous Search Referral from Doctor Insurance List Seen on TV Commercial Magzine/News Paper Sign

Check if you have these symptoms: (check all that apply) How often do you have sinsuits (facial pain/presure)? Are you having difficulty using your CPAP machine?       Snoring Mouth Breathing Stop breathing at night Daytime tiredness Daytime tiredness Weight Gain Nasal Obstruction Sneezing Runny Nose Post nasal drip Watery or itchy eyes Nose bleeds Loss of smell Pressure in the head/sinus Headaches Driziness/Vertigo Ear drainage Ear fullnesss or pressure Ear pain Noise or ringing in the ears Worsening hearing Heartburn Fever Bad breath Hoarseness Difficulty Swallowing Dry Mouth Difficulty in breathing Unexplained weight loss   Constantly Never     How have you treated your sinus infection? (Check all that apply)   Antibiotics Nasal Steriod Sprays (ex. Nasonex) Nasal Decongestants (ex. Afrin) Salt Water Sprays Decongestants Antihistamines     Have you had a sleep study?   Yes No   (If yes, please obtain the study or call our office so we may obatin the study for you)     Were you recommended a CPAP machine?   Yes No   Yes No     Why are you having difficulty using your CPAP machine?   Not a problem Claustrophobic Rash/irritation from mask Travel Pull mask at night Leaks     Check any ENT procedures you have had in the past   Tonsillectomy or Adenoidectomy Septoplasty Sinus Surgery UP3 (sleep apnea surgery) Rhinoplasty Voice Box (Larynx) Surgery Ear (Myrigotomy) Tubes Other Ear surgery Thyroidectomy

Check any conditions that you have or have had in the past? Does anyone in your family have of the following? Could you be pregnant (womens in childbearing years)?       AIDS/HIV Epilepsy (seizure) Multiple Sclerosis Alcoholism Gastroesophageal Reflux Peptic ucler disease Anemia Goiter Pneuomia/ Bronchitis Anxiety/ Panic Attack Heart Disease (heat attack, CHF) Pcychiatric Care Arthritis Hepatitis or liver disease Rheumatic Fever Asthma High blood pressure Scarlet Fever Bleeding disorder High cholesterol Syphilis Chemical dependency Immune deficiency Sleep apnea Depression Kidney disease Stroke Diabetes Lung Disease Thyroid diorder Emphysema Migraines Tuberculosis Cancer   Cancer Allergies Diabetes Thyroid disease Bleeding disorders Heart disease Problems with anesthesia Sleep apnea Hearing loss         Do you have any other medical conditions?     Have you had any other surgeries or procedure?     Yes No     Explain if answered yes?   Yes No     List all prescription and non-prescription medications you currently take.   List medication if any     Do you take Aspirin Courmadin, Plavix, or other blood thinners?   Yes No         Do you take diet pills?   Yes No   List medication if any

Do you smoke? Have you or currently used "street drugs"? Do/have you drink alcohol?   Yes No   have you smoked in the past?   Yes No       Yes No   What Type?       No Socially One glass of wine ervery day Heavy

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any memebr of the office staff responsible for errors or omissions that i may have made in completing this form.

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