PATIENT'S NAME ______________________________________

PATIENT'S SIGNATURE _________________________________

ADDRESS ____________________________________________

ADDRESS ____________________________________________

PHONE NUMBER ______________________________________

SURGEON ____________________________________________

DATE OF SURGERY ____________________________________

You (or your child) are to have surgery in the near future. For the benefit of all our patients and physicians, we are trying to determine how successful our recommended surgeries are in eliminating the patient's problems. We ask you to take a minute and answer the following 4 questions.

1. How many throat infections consisting of fever, swollen tonsils, and swallowing trouble have you or your child had in the past 12 months?
0	1 or 2	3 to 5	more than 5
2. How many times in the last year have you or your child seen the doctor or received antibiotics for throat infections?
0	1 or 2	3 to 5	more than 5
3. Do you or your child snore loudly and/or stop breathing at night?
Yes	No
4. Do you or your child have chronic bad breath?
Yes	No

* Please print this form, complete it and bring or mail it to our office. Our mailing address can be obtained from our Office Information page.