CENTER FOR ENT-HEAD AND NECK SURGERY
PATIENT INFORMATION SHEET
Name
*
First Name
Middle Name
Last Name
Birthdate
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Age
*
Nationality
*
Gender
*
Male
Female
Others
Marital Status
Please Select
Married
Widowed
Separated
Divorced
Single
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Religion
*
Contact Number
*
Please enter a valid phone number.
Format: (+63) 000-000-0000.
Email address
*
example@example.com
Smoking History
*
Yes
No
No. of stick per day
Duration
Alcohol use
*
Yes
No
Duration
Pregnant
*
Yes
No
Last menstrual Period(LMP)
REVIEW OF SYSTEM
*
Epistaxis/ nosebleedin
ear discharge
Headache
dizziness
hearing loss/ear clogged/ear pain
Cough
ringing sound of the ear
colds
fever
decreased sense of smell/taste
difficulty of breathing
diificulty of swallowin
hoarseness
neckmass
others
Others
PAST MEDICAL HISTORY
Allergies
Asthma
Cardiac disease
Hypertension
Diabetes
Surgery
Others
Others
Surgery
Medication taken:( if any)
Back
Next
Doctor Schedule
Please Select
DR. FRANCIS CHAN
DR. BENEDICT PADRINAO
DR. FERDINAND PAMINTUAN
DRA. FORTUNA ROLDAN
DR. RAMON KATIGBAK
DR. AL SANTIAGO
DR. DENNIS MANGOBA
DR GODOFREDO HIZON
DR. RUBEN EMIL HENSON
Dr. Chan - Appointment
Dr. PADRINAO - Appointment
Dr. Pamintuan - Appointment
Dr. Roldan - Appointment
Dr. Katigbak - Appointment
Dr. Santiago - Appointment
Dr. Mangoba - Appointment
Dr. Hizon - Appointment
Dr. Henson - Appointment
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