REASON FOR VISIT: DURATION:

EAR PROBLEMS Ear Infection -   Number per year Dizziness/Vertigo Injury to Ear Noise Exposure Hearing Loss Gradual /Sudden Ear Noises Difficulty Understanding Family History of Hearing Loss Previous Ear Surgery   Right / Left NOSE PROBLEMS Stuffiness/Blockage Postnasal Drip Nosebleed Snoring Loss of Smell Injury to Nose -   When Sinus Infections -   Number per year Runny Nose Sneezing Hay Fever THROAT PROBLEMS Strep Throat -   Number per year Tonsillitis -   Number per year Swollen Glands Hoarseness Coughing Up Blood Mouth Breathing Bad Breath PERSONAL HISTORY Smoke -   Amount Drink -   Amount Occupation: Religion: REFERRING PHYSICIAN

PAST HISTORY: Medical Problems Glaucoma            High Blood Pressure Arthritis             Heart Attack Asthma                Chest pain Emphysema         Heart Failure Ulcers                  Stroke Acid Reflux         Mitral Valve Prolapse Hepatitis              Palpitations Liver Disease      Rheumatic Fever Diabetes               Kidney Hypoglycemia      Prostate Thyroid                 Migraine Cholesterol          Seizures Blood Transfusion Lymphoma/Leukemia Immune System Disorder PREVIOUS SURGERY: (List all surgeries) Type and Date: MEDICATIONS NOW TAKING: (Include over-the-counter medication and aspirin) Type and Date: DRUG ALLERGIES: Type: FAMILY HISTORY: Allergy Heart Disease/Blood Pressure Cancer Anesthesia Problem Bleeding Disorders Muscular Dystrophy Diabetes Mother: Alive / Deceased      Cause: Father: Alive / Deceased      Cause: