Antibiotic History Testing/Surgery

Roman J. Dykun, M.D., F.R.C.S. (C) ? Christopher B. Standage, M.D. S. Alex Kim, M.D. ? Mobeen A. Shirazi, M.D.

Name: _______________________________________

Date: _____________________________

Date of birth: __________________________________

How long have you had your symptoms? ______________________________________________________

What symptoms do you experience? (check all that apply)

Nasal congestion Runny nose Fever Headache Change in smell/taste

Sneezing Cough Pressure in ears Hoarseness Other: ________________

Postnasal drainage Sore throat Facial pain/pressure Snoring

What have you taken OVER THE COUNTER in the past for your symptoms? (check all that apply)

Claritin/Loratadine Benadryl Xyzal/Levocetirizine Neti Pot Tylenol Cold and Sinus

Allegra/Fexofenadine Afrin Nasal Spray Saline Nasal Spray Ayr Sudafed

Zyrtec/Cetirizine Flonase Zicam Allergy Relief Advil Cold and Sinus Dayquil/Nyquil

What PRESCRIPTIONS have you taken in the past for your symptoms? (check all that apply)

Dymista QNasal Levaquin Amoxicillin Medrol Dose Pack Cephalexin Ceftin

Nasonex Astepro Cipro Zithromax Z-Pack Avelox Keflex Omnicef/Cefdinir

Palanase Astelin Augmentin Prednisone Doxycycline Atrovent Other: ______________

How many times were you treated with an antibiotic therapy in the past 12 months? _________

o Allergy Testing (if you have a copy, please bring to appointment) ? Date of test: ______________ ? Test Results: _____________________________________________________ ? Did you do allergy desensitization (allergy injections)? Yes/No If yes, for how long? __________________

o Sinus CT (if you have a copy of your images and report, please bring to appointment): ? Date of test: ______________ ? Test Results: _____________________________________________________

Allergy ? Endoscopic Sinus Surgery ? Snoring--Sleep Apnea ? Neurotology ? Balance Disorders ? Audiology ? Hearing Aid Dispensing DermaVita MediSpa ? ? Facial Plastic & Reconstructive Surgery

2441 Lake Shore Drive ? Woodstock, IL 60098-6911 ? 815/338-4600 ? Fax: 815/338-4611 ? E-mail: affentdocs@

Advocate GSH Building 1 ? 27790 W. Hwy. 22, Suite 11 ? Barrington, IL 60010 ? 224/655-7880 Northwestern Medicine ? 11650 Route 47 ? Huntley, IL 60142 ? 847/515-8400

Northwestern Medicine ? 4309 W. Medical Center Drive, Suite B100 ? McHenry, IL 60050 ? 815/363-0400

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