PAST HISTORY

Hill Country Ear, Nose & Throat, P.A.
Full Name
DOB
Age
Primary Doctor if any
Referring Doctor if any
Pharmacy
Pharmacy Address
CHIEF COMPLAINT
Describe the problem that you are being seen for today
How long have you had these symptoms
Facial Pain Headache Infections Sinus Pressure
PAST HISTORY
Hepatitis B Hepatitis C High Blood Pressure

Anemia Asthma Bladder Cancer Bronchitis

Hyperthyroidism Hypothyroidism Kidney Disease

Coagulation Defect Congestive Heart Failure

Neck: Malignant, Thyroid Mass Nose: Nasal Fracture, Closed

Diabetes, Type 1 Diabetes, Type 2 Drug dependence Enlarge Prostate Fatigue

Pneumonia Rheumatic Fever Seizure
SURGICAL HISTORY
Urinary Tract Infection (Please list all surgeries - Especially ENT surgeries like tonsillectomy, nasal surgery, etc Operation
PLEASE TURN OVER
MEDICATIONS(Please list all medications including aspirin, advil, blood thinners, birth control pill, etc. - Attach if needed) MedicationDoseFrequencyMedicationDoseFrequency

Do you take any herbal medications or supplements?
Please List
NKDA (No Known Drug Allergies)

FAMILY HISTORYCheck ( ) if your blood relatives have had any of the following. Relationship to you Allergy Thyroid Cancer Anesthesia problems Bleeding Tendency

MaybeIf Yes / Maybe date of last Menstrual Period:
Total number of pregnancies
Date of Last Menstrual Period

MonthDayYear
Date
If Yes Maybe date of last Menstrual Period

MonthDayYear
Date
Packs each day
For how many years
When did you stop
Do you / did you use oral tobacco?
Times each day
For how many years
When did you stop
Do you / did you ever drink alcohol?
Drinks each day
For how many years
When did you stop
Do you / did you drink coffee / caffeinated drinks?
Cups each day
For how many years
Occupation If retired please list previous occupations and current activities
When did you stop
Date stopped working

MonthDayYear
Date
Heat Intolerance Cold Intolerance

Night Sweats Weight Loss Weight Gain Fatigue

Heart Rhythm Problems Neurologic RespiratoryWeakness Numbness Speech Difficulties Coughing Up Blood Cough

Psychiatric Depression Anxiety Hemat/Lymph

Limited Range of Motion in the Neck

Easy Bleeding Easy Bruising Bleeding after Surgery

Burning Drainage Itching Dry Eyes
SIGNATURE of person completing the form

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© Copyright 2000 Kathy Keene Consulting Unpublished Work All Rights Reserved
DATE

MonthDayYear
Date
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PAST HISTORY

SURGICAL HISTORY

PLEASE TURN OVER