Shasta ENT Specialists Redding SINUS Center George H. Domb M.D. NEW PATIENT/SINUS INFORMATION. Patient Name: Date: Birth Date: M/F:

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1 Shasta ENT Specialists Redding SINUS Center George H. Domb M.D. NEW PATIENT/SINUS INFORMATION Patient Name: Date: Birth Date: M/F: Family Doctor: Referred By: Reason for Your Visit: Below you will find a list of symptoms, functional limitations, and emotional consequences of your rhinosinusitis. We would like to know more about these problems and how they impact your life. There is no right or wrong answers, and only you can provide us with this information. Please rate your problems as they have been RECENTLY. Do not hesitate to ask our doctors or staff members for help if necessary. Please refer to the following instructions and scales, circle the number that most accurately describes your experience. Magnitude Scale Considering how severe the problem is, when you get it and how frequently it happens, Please rate each item below on how bad it is using the following scale. Importance Scale For each item that has a magnitude of 1,2,3,4, or 5, please rate how important it is to you. Use the following scale. 0 = Not present/no problem 1 = Not important 1 = Very mild problem 2 = Somewhat important 2 = Mild to slight problem 3 = Moderately important 3 = Moderate problem 4 = Extremely important 4= Severe problem 5 = Problem is as bad as it can be 1. Nasal Symptom MAGNITUDE IMPORTANCE Stuffy/blocked nose Runny nose Sneezing Decreased sense of smell or taste Postnasal discharge Thick nasal discharge/debris Bloody nose Eye Symptoms Itchy, watery eyes Swollen, sore eyes

2 3. Sleep MAGNITUDE IMPORTANCE Difficulty getting to sleep Wake up during the night Lack of a good night s sleep Wake up tired General Symptoms Fatigue/worn out Reduced productivity Poor concentration Headache Facial pain/pressure Cough Short of breath Practical Problems Need to rub nose/eyes Need to blow nose repeatedly Bad Breath Tobacco Use: Y/N Since Quit? When? Chew Cigarettes Packs/Day Pipe Cigar 7. Alcohol Use: Never Daily Weekly Social Quit? When 8. Allergies to Medication: 9. Medications you are now taking( including over the counter): 10. Medications you have taken in past(and way): 11. Do you take Blood Thinners No Yes Plavix Aspirin Ibuprofen Persantine Coumadin

3 PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING Diabetes High Blood Pressure Hepatitis Asthma/Lung Problems Bleeding Tendency Thyroid Problems AIDS/HIV+ Chest Pain/Stroke Ulcer Heart Attack/When? Prev. Ear Surgery Stroke Nose/Sinus Surgery Loud Noise Exposure 12. Please List Any Prior Surgeries: 13. Ladies: Could You Be Pregnant? Would you like Dr. Domb to know anything else about you? THANK YOU FOR FILLING OUT THIS FORM COMPLETELY

4 Shasta ENT Specialists Redding SINUS Center George H. Domb M.D. NEW PATIENT MEDICAL INFORMATION SHEET Patient Name: Date: Birth Date: M/F: Family Doctor: Referred By: Reason for Your Visit: 1. Ears: Itchy Pain Drainage Hearing Loss Ringing Dizziness PLEASE CHECK ANY CURRENT SYMPTOMS 2. Nose and Sinus: Runny Nose Post-Nasal Drip Stuffy or Congested Nosebleeds Problems with sense of smell Polyps 3. Mouth and Throat: Sore Throat Tonsillitis Mouth Breathing Problems Swallowing Hoarseness 4. Snoring: Yes No Daytime Sleepiness 5. Tobacco Use: Y/N Since Quit? When? Chew

5 Cigarettes Packs/Day Pipe Cigar 6. Alcohol Use: Never Daily Weekly Social Quit? When 7. Allergies to Medications: 8. Medications you are now taking, including over the counter: 9. Medications you have taken in past(and way): 10. Do you take Blood Thinners? No Yes Plavix Aspirin Ibuprofen Persantine Coumadin PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING Diabetes High Blood Pressure Hepatitis Asthma/Lung Problems Bleeding Tendency Thyroid Problems AIDS/HIV+ Chest Pain/Stroke Ulcer Heart Attack/When? Prev. Ear Surgery Stroke Nose/Sinus Surgery Loud Noise Exposure 11. Please List Any Prior Surgeries: 12. Ladies: Could You Be Pregnant? Would you like Dr. Domb to know anything else about you?

6 THANK YOU FOR FILLING OUT THIS FORM COMPLETELY

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