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GENERAL INFORMATION: Today’s Date: _____/_____/_____ Patient’s Name: ________________________________________________ Date of Birth: _____/_____/_____Patient’s Height: ____________________ Patient’s Weight: ____________________Preferred Phone Number: (_____)_____________ Email:_____________________________________________Primary Care Physician:________________________________________________________________________ Did a physician refer you to Lakeshore ENT? ? Yes ? No If “Yes,” which physician:____________________________ Where (hospital system) does your physician send you to for testing? ____________________________________How did you hear about us if you were not referred by a physician? ? Family ? Friend ? Internet ? OtherPreferred Pharmacy (name and phone number): _______________________________________________________CHIEF COMPLAINT (reason for visit): _______________________________________________________________SINUS SYMPTOMS (please check all that apply): How frequently do you have these symptoms?Sinus InfectionFacial Pressure, Pain, HeadacheNasal Congestion, StuffinessRunny Nose, Post-nasal DripNasal BleedingAltered SmellAsthmaNeverThis is the 1st episode3 times/year or fewer4-6 times/yearMonthlyWeeklyDailyConstantlyDo you HAVE any of the following? If your answer is “No,” skip to the next section. Recurrent sinus infections...........................................................................? Yes ? NoHow often? ______________________________What antibiotics have you taken for this? ______________________________What’s the longest course of antibiotics or steroids you had? ______________________________When was your last treatment? ______________________________Nasal discharge or post-nasal drip..............................................................? Yes ? NoIf yes, ? Left ? Right ? Both If yes, ? Discolored ? Clear If clear, does it taste salty? ? Yes ? NoIs it worse with bending, lifting or straining? ? Yes ? NoNasal bleeding.................................................................................? Yes ? NoIf yes, ? Left ? Right ? Both If yes, ? Mild ? Moderate ? Severe Is it worse in the winter? ? Yes ? NoIs it worse with nose sprays? ? Yes ? NoNasal congestion or blockage..........................................................? Yes ? NoIf yes, ? Left ? Right ? Both If both, is it alternating? ? Yes ? No Please list things that make the congestion worse (e.g., smoking, allergies, infections, lying down). _______________________________________________________________________________Facial, pressure, pain, or headache................................................? Yes ? NoWhen did this first begin? ______________________________ Which side of your head or face is affected? ? Left ? Right ? Both What locations are affected? ? Forehead ? Cheeks ? Behind the eyes ? Temples ? Back of head ? Neck ? Teeth How would you best describe the pressure or pain? ? Dull ache ? Sharp stabbing ? Pressure ? ThrobbingWhat triggers the pressure or pain? ? Weather changes ? Allergies ? Menstrual cycle ? FoodsDo you get associated nausea or vomiting? ? Yes ? NoDo you get light sensitivity? ? Yes ? NoIs there a family history of migraines? ? Yes ? NoHave you been diagnosed with migraines? ? Yes ? NoHave you been diagnosed with TMJ (jaw issues), or told you clench/grind your teeth? ? Yes ? NoHave you had prior imaging of your head or sinuses…………….................? Yes ? NoIf yes, what did you have? ? CT (cat scan) ? MRI If yes, do you have a copy of the results or a disc? ? Yes (please bring to next visit) ? No Do you suffer from allergy symptoms?.............................................? Yes ? NoIf “Yes,” which symptoms? ? Sneezing fits ? Itchy eyes ? Itchy nose ? Scratchy throat ? Watery eyes ? Runny nose How long have you had these symptoms? _____________________________ When are the symptoms worse? ? Spring ? Summer ? Fall ? Winter Have you ever been tested for allergies? ? Yes ? No If so, who tested you and what were you allergic to? ____________________________________ How long ago was the testing? ______________________________Did you get allergy shots? ? Yes ? NoHow long did you get the shots? ______________________________Do you think the shots helped? ? Yes ? NoDid you have to stop the shots prematurely? ? Yes ? NoSmell or taste changes.....................................................................? Yes ? NoWhen did this first begin? ______________________________ What was affected? ? Smell ? Taste ? Both Is the sensation lost? ? Yes ? NoIs the sensation altered? ? Yes ? No If “Yes,” in what way? ______________________________Is your sense of smell diminished with infections? ? Yes ? NoDo antibiotics or steroids make these symptoms better? ? Yes ? NoWhich describes your experience with the following therapies for each problem? 0 – Never used1 = No relief2 = Some relief but difficulty tolerating3 = Some partial or temporary relief4 = Significant relief(enter the best number for each therapy used in the boxes below each symptom)Sinus InfectionFacial Pressure, Pain, HeadacheNasal Congestion, StuffinessNasal DischargeAltered SmellAsthmaAntibioticsAnti-fungal therapy (Sporanox, Vfend, Ampho B)Anti-histamines (Benadryl, Claritin, Allegra, Zyrtec)Decongestants (Sudafed, Entex, Etc.)Topical nasal steroid sprays (Nasacort, Rhinocort, Flonase, Nasonex)Steroids by mouth or injection (Medrol or Prednisone)Over-the-counter nose sprays (e.g., Afrin)Aspirin, Tylenol, Anti-inflammatoryPrescription pain medications (Codeine, Percocet)Antibiotic nasal/sinus irrigationsMAJOR SURGERIES:WhatWhere (what facility?)When1.2.3.4.MEDICATIONS:Medication list attached: ? Yes ? No If “No,” list all current medications below, including dose and frequency: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________List medication allergies and reactions: _________________________________________________________________________________________________________________________ ______________________________ MEDICAL HISTORY (please check all that apply):?Allergic Rhinitis?Cancer (what area of body??Migraines?Anesthesia Problems?COPD (lung disease)?Hepatitis?Reflux (GERD)?Asthma?Diabetes?High Blood Pressure?Stroke?Anxiety?Heart Disease?Kidney Disease?Thyroid Disease?Autoimmune Disorder?Other (please specify):?Blood ClotsFAMILY MEDICAL HISTORY (please check all that apply and note relationship):? Hearing Loss? Cancer? Heart Disease? Bleeding Disorders? Hearing Loss? High Blood PressureSOCIAL HISTORY:Smoking/tobacco products (cigarettes, cigars, chewing tobacco): ?Yes ?NoNumber of years: Number of packs/day: When did you quit? What is your occupation? Are you retired? ?Yes ?No Alcohol: ?Yes ?No Daily amount: How long? When did you quit? Do you use recreational/illicit drugs? ?Yes ?No If yes, what drugs? Are you hard of hearing or deaf in one or both ears? ?Yes ?NoDo you have special religious, spiritual, or cultural needs that we should to be aware of? ?Yes ?NoIf Yes, please explain:REVIEW OF SYSTEMS (please check all that apply):Constitutional: ?fatigue ?fever ?weight loss (__________lbs) ?weight gain (__________lbs)Eyes: ?blurred vision ?double vision ?itching ?burning ?eye painEars: ?difficulty hearing ?ear pain ?vertigo ?tinnitus (ringing) ?ears feel pressured ?discharge from earsNose: ?frequent nosebleeds ?nasal congestion ?nose/sinus problems ?rhinorrhea (nasal mucus) ?sinus pressure ?blockage/obstructionMouth/Throat: ?sore throat ?bleeding gums ?snoring ?dry mouth ?oral abnormalities ?mouth ulcer ?teeth abnormalities ?difficulty swallowing ?post nasal drip ?hoarseness ?mouth breathingNeurologic: ?fainting ?frequent headaches ?seizures ?numbness ?weakness ?migraines ?restless legsCardiovascular: ?chest pain ?history of heart murmur ?dyspnea on exertion ?palpitations ?edema ?light-headed on standing Respiratory: ?wheezing ?shortness of breath ?hemoptysis ?sputum production ?sleep apnea ?coughGenitourinary: ?difficulty urinating ?pain during urination ?urinary retentionGastrointestinal: ?vomiting ?heartburn ?painful swallowing ?no appetite ?increased appetiteHematologic/Lymphatic: ?swollen glands ?easy bruising ?excessive bleedingPsychiatric: ?depression ?anxiety ?restless sleepMusculoskeletal: ?muscle aches ?joint pain/arthralgiaSkin: ?rash ?itching ?dry skin ?growths/lesionsEndocrine: ?increased thirst ?increased drinking ?increased hungerAllergy/Immunologic: ?frequent sneezing ?runny nosePatient/Guardian Signature: ___________________________________________________________________ ................
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