Ear Institute of Chicago, LLC
11 Salt Creek Lane , Suite 101 Hinsdale, IL 60521 |
233 E. Erie, Suite 701 Chicago, IL 60611 |
800 Biesterfield Road, Ste 4001 Elk Grove Village, IL 60007 |
PATIENT HEALTH HISTORY
Patient Name:__________________________________________Date of Birth:__________________
CHIEF CONCERN
Reason for today's visit:_______________________________________________________________
PAST MEDICAL HISTORY
Please list any prior major illnesses and/or injuries:_________________________________________
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SURGERIES/HOSPITALIZATIONS |
YEAR |
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MEDICATIONS (List Name, dosage and frequency)
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5. |
9. |
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10. |
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11. |
4. |
8. |
12. |
DRUG ALLERGIES :________________________________________________________________
FAMILY HISTORY
(List family member and history of hearing loss, dizziness, migraine or acoustic tumor)
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SOCIAL HISTORY
Occupation:_________________________________________________________________________
History of smoking?: No ____ Yes ____ If yes, what type and for how long?____________________
History of alcohol use: No_____ Yes____ How often?______________________________________
REVIEW OF SYSTEMS (Please circle all items that you have had problems with)
Allergic/Immunologic: Food Allergies Immunologic Disorder(s):__________ Inhalant (nasal) Allergies
Cardiovascular: Chest pain or angina Heart Murmur Irregular Pulse Leg Pain/Cramping While Walking Palpitations Swelling in Hands and/or Feet
Constitutional: Excessive Fatigue Fever Night Sweats Weight Loss
Dermatologic (Skin): Skin Cancer Skin Disease
Endocrine: Excessive Thirst Excessive Urination Hormone Problems Increased Appetite |
Ear, Nose, Throat: Dizziness:
Ear Drainage Ear Fullness Ear Pain Hearing Loss Inability to Smell Mouth Sores Nasal Congestion Nasal Drainage Nose Bleeds Ringing (Noise) in the Ear(s): Left___ Right___ Both___ Sore Throat
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Neurological: Difficulty with Speech Disorientation Facial Numbness Facial Twitching Facial Weakness Fainting Spells or Blackouts Inability to Concentrate Memory Problems Migraine Headaches Problems with Coordination Seizures Tingling of Feet Tingling of Hands
Ob/Gynecology: Breast Cancer Cervical Cancer Preganancy Uterine Cancer
Ophthalmology (Eyes): Blurred Vision Diminished Vision Double Vision Eye Inflammation
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Gastroenterology: Abdominal Pain Change in Bowel Habits Colon Cancer Nausea Ulcers or Gastritis Vomiting
Hematologic/Lymphatic: Anemia Bleeding Tendency Hemophilia
Musculoskeletal: Arthritis Back Pain Broken Bones Joint Pain Joint Swelling
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Psychiatric: Anxiety Depression Sleep Disturbance Suicidal Thoughts
Respiratory: Chronic Cough Lung Cancer Shortness of Breath Wheezing
Urology: Blood in your Urine Dialysis Difficulty Urinating Kidney Stones Prostate Cancer |
The above information is accurate to the best of my knowledge:
Patient (or Guardian) Signature:_____________________________________________ Date:____________
The above information has been reviewed with the patient and is deemed correct:
Physician:_______________________________________________________________ Date:____________