Female. Separated. Non-Hispanic/Latino. Unknown
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1 Patient Information Today s Date Patient s Legal Name Other names patient uses Male SSN - - Marital Status Single Ethnicity Hispanic/Latino Married Female Separated Non-Hispanic/Latino Date of Birth / / Divorced Widowed Prefer not to answer Race Asian Black or African American White or Caucasian American Indian and Alaska Native Native Hawaiian and Other Pacific Islander Unknown Prefer not to answer Other Address _ City State Zip Home Phone Work Phone Mobile Phone Address Primary Care Provider Emergency Contact Name Emergency Contact Relationship Emergency Contact Phone Number (home/work/mobile) How did you hear about ADVENT? Radio Television Online ADVENT Seminar Doctor Referral: Patient Referral: I am re-establishing care at ADVENT Employee Referral: Other:_ Communication Preferences We wish to engage with you via a brief survey regarding your care, clinical improvement and satisfaction. Preferred method of survey engagement: Mobile Please note, by proving your mobile number, you are consenting to receive the survey via text. If you would like to receive our newsletter via , check here
2 Comprehensive Patient History Form Patient Name: Today s Date: Date of Birth: What is the reason for today s visit? Where is your or symptom located? How severe is your? Mild Moderate Severe How long have you had this? When does this occur? Is it constant or intermittent? Where were you or what were you doing when this started? Does anything else happen with this? Does anything make it worse or better? Allergies Do you have a latex allergy? No If yes, please list: Do you have a medication allergy? No If yes, please list: List medications you are currently taking or attach list.... Surgical History Obstructive Sleep Apnea... No Asthma... No Diabetes... No Hypertension... No Stroke... No. Heart trouble... No 6. Arthritis/gout... No 7. Bleeding tendency... No 8. Cancer... No 9. Type of cancer:... Other pertinent medical history:
3 List previous Hospitalizations/Surgeries/Serious Injuries When? Previous imaging of the nose or sinuses? No When: Where: Previous sleep study? No When: Where: Previous allergy testing? No When: Where: Previous hearing test? No When: Where: Do you use CPAP? No Social/Environmental History Do you live in a house, apartment or townhouse? Age of property Type of heat: Forced air Radiator Other Type of air conditioning: Central Wall unit None Are there pets in the home? Type of pet: No Type of mattress cover: Cotton Allergy proof Type of pillow: Synthetic Feather History of mold, mildew or flooding? No Type of flooring: Carpet Wood Tile Laminate Presence of roaches or mice? No Smoking status: Never smoked Current smoker Previous smoker Second hand smoke exposure Occupation: Hobbies: Family Medical History List any medical condition in family members that you feel may be related to your current medical : Patient Social History Marital Status: Single Married Separated Divorced Widowed Use of alcohol: Never Rarely Moderate Daily Use of tobacco: Never Previously but quit Current packs per day Use of illicit drugs: Never Type/Frequency Excessive exposure at home or work to: Fumes Dust Solvents Noise
4 Have you had any of the following symptoms in the past months? CONSTITUTIONAL Fever... No Chills... No Weight loss... No Malaise/Fatigue... No Weakness... No SKIN Rash... No Itching... No HENT Headaches... No Hearing loss... No Tinnitus... No Ear pain... No Ear discharge... No Nosebleeds... No Congestion... No Stridor... No Sore throat... No EYES Blurred vision... No Double vision... No Sensitivity to light... No Eye pain... No Eye discharge... No Eye redness... No CARDIOVASCULAR Chest pain... No Palpitations... No Cramping... No Leg swelling... No Shortness of breath at night... No RESPIRATORY Cough... No Coughing blood... No Sputum production... No Shortness of breath... No Wheezing... No GASTROINTESTINAL Heartburn... No Nausea... No Vomiting... No Abdominal pain... No Diarrhea... No Constipation... No Blood in stool... No Dark stools... No GENITOURINARY Painful urination... No Urgency... No Frequency... No Blood in urine... No Flank pain... No MUSKULOSKELETAL Muscle pain or cramps... No Neck pain... No Back pain... No Joint pain... No Falls... No ENDOCRINE/HEMATOLOGIC/ALLERGIES Easily bruise or bleed... No Environmental allergies... No Excessive thirst... No NEUROLOGICAL Dizziness... No Tingling... No Tremor... No Sensory change... No Speech change... No Focal weakness... No Seizures... No Loss of consciousness... No PSYCHIATRIC Depression... No Suicidal ideas... No Substance abuse... No Hallucination... No Nervous/anxious... No Insomnia... No Memory loss... No To the best of my knowledge, this information is complete and correct. I understand that it is my responsibility to inform ADVENT if there are any changes to my health. Patient Signature:
5 Office Visit & Procedure Charges Disclosure ADVENT knows that understanding healthcare costs is important to patients and we want to provide transparency of potential charges associated with visits. Office Visit charges cover the cost of your appointment with the physician, nurse practitioner or physician assistant (or combination thereof) on the day of your appointment. This charge does not cover any diagnostic testing, procedures, labs, cultures, scopes (endoscopy camera), CT Scans, audiological testing, allergy testing or supplies that may be appropriate or recommended before, during or after your visit with our medical provider. **Note: As part of your initial visit to ADVENT, an endoscopy (scope evaluation) is a typical procedure to be recommended, to fully evaluate your anatomy and to assist in treatment evaluation. The endoscopy is a separate procedure charge from the office visit, which will be billed to your insurance. The endoscopy may be repeated during any visit to assist in evaluation and treatment recommendations. Your insurance company may or may not cover some or all of the costs of these additional tests or services and you have the right to accept or refuse any of these services. However, refusing diagnostic testing, procedures, labs, cultures, scopes (endoscopy camera), CT Scans, audiological testing, allergy testing or supplies could limit the medical provider s ability to properly diagnose and treat your medical condition, and may limit our ability to provide an appropriate surgical/procedure, treatment or solution. ADVENT is a specialty clinic. We recommend contacting your insurance plan if you have questions on whether a service is covered through your specific plan and to verify charges that may/may not apply to out of pocket costs (deductible, copay, etc.) as part of your visit(s) to ADVENT. Patient Name Date of Birth Signature of Patient (or person acting on patient s behalf) Date
6 Sinus and Sleep Patient Medication Worksheet Patient Name Date of Birth: / / Date Please complete if you are being seen for sinus, sleep or allergy symptoms. List what medications you are currently taking for these symptoms and what you have tried in the past. Antibiotics (examples: Augmentin, Amoxicillin, Bactrim, Levaquin, Doxycycline) Nasal sprays (example: Nasonex, Flonase, Fluticasone, Astepro, Patanase, Nasacort, Zetonna, QNASL) Oral Decongestants (examples: Sudafed, Mucinex-D, Coricidin) Oral Antihistamines (examples: Claritin, Zyrtec, Allegra) Anticoagulants ( blood thinners ) and Supplements (examples: Warfarin/Plavix/Advil/Aleve/Ibuprofen/Motrin/Omega/Fish Oil)
7 SNOT Sino-nasal Outcome Test ( Questions) Please complete if you are being seen for sinus/allergy symptoms. Patient Name Please rate each question below based on a scale of -. No Very mild Visit Date Date of Birth Mild or slight Moderate Severe Problem as bad as it can be. Need to blow nose. Sneezing. Runny nose. Cough. Post nasal discharge (dripping at the back of your nose) 6. Thick nasal discharge 7. Ear fullness 8. Dizziness 9. Ear pain/pressure. Facial pain/pressure. Difficulty falling asleep. Waking up at night. Lack of a good night s sleep. Waking up tired. Fatigue during the day 6. Reduced productivity 7. Reduced concentration 8. Frustrated/restless/irritable 9. Sad. Embarrassed. Sense of taste/smell. Blockage/congestion of nose Most important items TOTAL SNOT Score Comments: First Visit CT Visit IOBS Visit 6 Week Follow-up 6 Month Follow-up Month Follow-up MRN#
8 Authorization for Release of Verbal Communication Please complete to authorize ADVENT to speak with family members or other individuals that may contact ADVENT on your behalf. If you do not wish to authorize anyone, select none. I, Patient Name _ DOB I authorize verbal communication and give permission to disclose the following information contained in my chart: All Medical Information All Billing Information To these persons: Name: Relationship: Name: Relationship: Name: Relationship: None Patient/Personal Representative Signature If Personal Representative, Describe Relationship Date
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