canyonviewent.com - Patient History Form

Patient Medical History and Authorizations
Date:

MonthDayYear
Date
Patient’s Name:
Date of Birth:

MonthDayYear
Date
Weight:
Height:
What is the reason for your visit today?
Past Medical History
Have you ever experienced any of the following?

AllergiesBleeding DisordersImmunological DisordersSleep ApneaAnemiaCancerKidney ProblemsStrokeAnesthesia ReactionChest PainMigrainesSubstance AbuseArthritisDiabetesSeizure DisordersThyroid DisordersAsthmaEar, Nose, and/or Throat problemsShortness of BreathBack PainSinus Conditions
Allergies

Are you allergic to any of the following?
Foods

YesNo
If yes, please list
Medications

YesNo
If yes, please list
Pet Dander

YesNo
Latex

YesNo
Pollen/Seasonal

YesNo
Other

YesNo
Family History

Please indicate if any of your immediate relatives have experienced any of the following

	Mother	Father	Siblings	Grandparents
Alcoholism
Anesthesia Problems
Asthma
Bleeding Disorders
Cancer
Cardiovascular Disease
Headaches/Migraines
Hypertension
Kidney Disease
Liver Problems
Seizures
Sleep Apnea
Stroke
Substance Abuse

Social History
Do you drink alcohol?

YesNo
If yes, how much?
Do you drink caffeine?

YesNo
If yes, how much?
Do you currently use tobacco?

YesNo
If yes, do you smoke or chew? How much?
Have you ever used tobacco in the past?

YesNo
If yes, when did you quit?
Have you ever used illegal drugs or abused prescription drugs?

YesNo
If yes, when?
Does anyone in your household smoke?

YesNo
Do you have pets in your home?

YesNo
For infants only, is the child in daycare?

YesNo
For infants only, does the child drink from a bottle?

YesNo
For infants only, does the child use a pacifier?

YesNo
Medications
Please list any and all medications that you are currently taking
Surgical History
Please list any surgeries you have had, indicating the year in which they occurred
Review of Symptoms
Which symptoms are you currently experiencing?

FeverVision ChangesDizzinessBloody NoseHeadacheHearing LossEar InfectionEar PainSinus CongestionSleep ApneaSnoringSore ThroatTinnitusChest PainHypertensionAsthmaCoughShortness of BreathBleeding DisordersKidney ProblemsBack PainDermatitisRashSeizuresThyroid DiseaseAllergiesOther
CONSENT FOR TREATMENT: By signing below, I hereby authorize Dr. Robert Pearson to perform diagnostic, medical and/or surgical procedures on me and to administer medication to me as may be necessary for proper health care.

AUTHORIZATION TO RELEASE INFORMATION: By signing below, I hereby authorize Dr. Robert Pearson to release any medical information necessary for medical reasons or in processing claims for insurance benefits and/or applications for final benefits, including but not limited to Rehabilitation Services, Social Security Benefits and Worker’s Compensation Benefits.

Further, I hereby authorize Canyon View Ear, Nose & Throat to release any medical information or test results to myself or communicate through my answering machine, voice mail, text message email address or to any of the following persons:
Name:
Relation:
Phone Number:
Please enter a valid phone number.
Name:
Relation:
Phone Number:
Please enter a valid phone number.
AUTHORIZATION TO OBTAIN MEDICAL RECORDS AND INFORMATION: By signing below, I hereby authorize the release of any and all of my medical information to Dr. Robert Pearson from any physicians who have provided treatment to me, made diagnoses and/or performed procedures for the present or any related conditions, including any X-rays and laboratory results.

PRIVACY PRACTICES ACKNOWLEDGEMENT: By signing below, I acknowledge that I have read and reviewed the Health Insurance Portability and Accountability Act (HIPAA)-Omnibus Final Rule Privacy and Compliance Notice that I have been given opportunity for a copy, and to make changes by this office.
Patient/Responsible Party Signature

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Date
Patient Name
Date

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Patient Medical History and Authorizations

Past Medical History

Allergies

Family History

Social History

Medications

Surgical History

Review of Symptoms