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:_________________________
1.
PAST AND CURRENT MEDICAL HISTORY:
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:
Name:____________________________________________
9.
REVIEW OF SYSTEMS: Check any symptoms that you /the patient have now or have recently had.
Fever
10.
ALLERGIES: Are you allergic to any of the following? Check all that apply.
□ Latex
11.
DRUG ALLERGIES: □ NONE
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)______________________
Source: http://www.kyent.com/Media/54/KYENT_Medical_History.pdf
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