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1 University of Texas Medical School at Houston Department of Otorhinolaryngology- Head & Neck Surgery Texas Sinus Institute New Patient Questionnaire Rev FINAL REV Page 1 of 7 SCAN THIS PAGE. Name MRN DOB Date Telephone H W M Pharmacy Name Telephone How did you hear about us? Sent by another physician (If so, please give name below.) Sent by a friend Internet search UT and/or TSI reputation Other (Specify) Physician #1 ( sent by this physician) Name Fax Telephone Address City, State Zip Physician #2 ( sent by this physician) Name Fax Telephone Address City, State Zip Important Note on Medical Records and Previous Imaging Please be sure to bring your previous medical records. In particular, previous CT scans and MRI scans of the nose and sinuses are very important. Please try to obtain the actual films (not just the radiology reports); images on CD-ROM are preferable. START HERE: What symptom gives you the most trouble?
2 Nasal Symptom Inventory Page 2 of 7 The following rating scale will be used to complete the questions: Scale Severity Definition 0 None Absent-NO symptom evident 1 Mild Symptom clearly PRESENT but minimal awareness; easily tolerated 2 Moderate Definite awareness of symptom that is bothersome, but tolerable 3 Severe Symptom is hard to tolerate; interferes with activities of daily living and/or sleeping Using the rating scale above, please rate the following symptoms according to how you feel right now. Facial or sinus pressure (pressure or fullness in the area behind the eyes, cheeks, forehead, or sinuses) Facial or sinus pain (pain in the area around the eyes, cheeks, forehead) Headache (dull to intense, throbbing pain in head) Nasal congestion (stopped up or stuffy nose) Nasal obstruction (inability to move air through the nose) Post-nasal drip (sinus drainage in the back of the throat) Clear nasal discharge (nasal mucus that is clear) Discolored nasal discharge (nasal mucus that is green, yellow, and/or brown) Itchy nose/eyes/throat (sensation of itchiness in the nose, eyes and/or throat) Nose bleeds (bleeding, not bloody mucus, from the nose) Tiredness (feeling worn out or drained due to chronic sinusitis) Wheezing (whistling sound from breathing, associated with chest tightness) Cough None Mild Moderate Severe Sense of smell (reduced sense of smell or detection of bad odor)
3 Most Important Items Problem as Bad as It Can Be Severe Problem Moderate Problem Mild or Slight Problem Very Mild Problem No Problem Sino-Nasal Outcome Test (SNOT-22) Page 3 of 7 SCAN THIS PAGE. Below you will find a list of symptoms and social/emotional consequences of your rhinosinusitis. We would like to know more about these problems and would appreciate your answering the following questions to the best of your ability. There are no right or wrong answers, and only you can provide us with this information. Please rate your problems as they have been over the past two weeks. Thank you for your participation. Do not hesitate to ask for assistance if necessary. Important: Please mark the most important items affecting your health (maximum of 5 items). Considering how severe the problem is when you experience it and how frequently it happens, please rate each item below on how "bad" it is by circling the number that corresponds with how you feel using this scale: 1. Need to blow nose Sneezing Runny nose Cough Post-nasal discharge (dripping at the back of your nose) Thick nasal discharge Ear fullness Dizziness Ear pain Facial pain/pressure Difficulty falling asleep Wake up at night Lack of a good night s sleep Wake up tired Fatigue Reduced productivity Reduced concentration Frustrated/restless/irritable Sad Embarrassed Sense of taste/smell Blockage/congestion of nose
4 General How frequently do you have sinus and nasal symptoms? This is the first episode. 3 times/year 4-6 times per year Monthly Weekly Daily Constantly Do your symptoms improve between episodes?, they completely improve, they never improve Sometimes, they improve They improve partially How often do your baseline symptoms get worse? Never (The symptoms are always the same.) 1-3 times/year 4-6 times per year More than 6 times per year Which best describes your sense of smell? problem with sense of smell Diminished sense of smell Loss of smell Detect bad odor Have you ever had a sinus CT or MRI scan? If yes, please provide details (including dates) below. Allergy Page Do you have any of these allergy symptoms? Sneezing fits Itchy ears Itchy eyes Itchy nose Runny nose Itchy throat Runny/watery eyes Scratchy roof of your mouth When are your allergy symptoms most apparent? Spring Summer Fall Winter Continuously throughout the year Have you ever been tested for allergy? Never I have had skin testing for allergy. I have had blood testing for allergy. Have you received allergy shots? Never, and they helped a great deal., and they helped somewhat., and they did nothing. Asthma Do you have asthma? Page 4 of 7 If yes, what do you take for your asthma? Asthma inhalers Nebulizer treatments Oral steroids Theophylline Other Have you ever had a sinus or nasal surgery? If yes, please provide details (including dates) below. Trauma Have you ever broken your nose? Have you ever sustained other facial and/or head injuries?
5 Previous Treatments Which antibiotics have you received over the past year? Amox and/or PCN Amox/clav (Augmentin) Azithromycin (Zithromax, Z-pak) Cefadroxil (Duricef) Cefdinir (Omnicef) Cefpodoxime (Vantin) Cefprozil (Cefzil) Cefuroxime (Ceftin) Cephalexin (Keflex) Ciprofloxacin (Cipro) Clarithromycin (Biaxin) Erythromycin Levofloxacin (Levaquin) Loracarbef (Lorabid) Moxifloxacin (Avelox) SMP/TMX (Bactrim, Sulfa) IV antibiotics ne Which antihistamines have you received over the past year? Cetirizine (Zyrtec) Cetirizine/decongestant (Zyrtec-D) Desloratadine (Clarinex) Desloratadine/decongestant (Clarinex-D) Diphenhydramine (Benadryl) Fexofenadine (Allegra) Fexofenadine/decongestant (Allegra-D) Levocetirizine (Zyzal) Loratadine (Claritin) Loratadine/decongestant (Claritin-D) ne Page 5 of 7 Which nasal sprays have you used over the past year? Beclomethasone (Qnasal, Beconase) Budesonide (Rhinocort) Ciclesonide (Omnaris) Flunisolide (Nasarel) Fluticasone furoate (Veramyst) Fluticasone propionate (Flonase) Mometasone (Nasonex) Triamcinolone (Nasacort) Oxymetazoline (Afrin) Azelastine (Astelin) Fluticasone/azelastine (Dymista) Olopatadine (Patanase) Ipratropium bromide (Atrovent) ne What other treatments have you used over the past year? Montelukast (Singulair) Zileuton (Zyflo) Antifungal treatments Guaifenesin OTC (Mucinex) Nasal saline sprays Nasal saline irrigations Oral decongestants Systemic steroids Topical antibiotic irrigations/treatments ne
6 Treated by another physician No Yes Treated by another physician No Yes Page 6 of 7 Review of Systems The following is a list of common symptoms and health problems. Please review the list and indicate with a check mark the symptoms and health problems that you are experiencing. General Gastro-intestinal Nausea Heartburn Weight gain Belly pain Weight loss Diarrhea Fevers/chills Constipation Ears, Nose & Throat Vomiting Hoarseness Skin Hearing loss Rashes Draining ear Ulcers Vertigo Musculo-skeletal Loud snoring Muscle pain Daytime sleepiness Muscle weakness Mouth sores Endocrine Tooth problems Painful/difficult swallowing Ringing in the ears Eyes Cold intolerance Heat intolerance Excessive thirst Hematologic Double vision Anemia Blurry vision Bleeding Cardiac Bruising Chest pain Neurological Short of breath Seizures Respiratory Psychiatric Wheezing Depression Cough Anxiety
7 Page 7 of 7 Past History Do you have any of the following medical problems? Arthritis Asthma Bleeding disorder Cataracts Chronic fatigue syndrome Depression Diabetes Fibromyalgia Gastritis Glaucoma Hepatitis High blood pressure Heart disease Immunodeficiency Kidney disease Meningitis Migraine headache Mitral valve prolapse Peptic ulcer disease Seizures Thyroid disease Tuberculosis (TB) Please list your previous surgical procedures. Please list your current medications. Are you allergic to any medications? (If yes, please give details.) Family History Do any of your family members have any of the following conditions? (Please specify the family member.) Allergy Asthma Bleeding disorder Cancer Social History What is your occupation? Cystic fibrosis Heart disease Immunodeficiency Please list your previous hospitalizations. Do you have any other medical problems not listed above? (If yes, please give details.) Have you had any recent change in your home or work environment? Do you smoke? Do you drink alcoholic beverages? Have you ever used cocaine or other illicit substances?.
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ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
NEW PATIENT VISIT QUESTIONNAIRE
HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Email: Preferred
Arcana Center for Integrative Medicine
Arcana Center for Integrative Medicine Patient s Name: Date of Birth: Reason for today s visit: Past Medical History Primary care physician: Date of last exam: (sick or well) Physician s Address: Office
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
New Sleep Patient Questionnaire. Name Age Date. General Medical History 1. Please list any surgeries you have had and their approximate dates:
1 John S. Kim, M.D., Diplomate ABSM Lawrence A. Lynn, D.O., FCCP 1251Dublin Rd. Columbus, Ohio 43215 (614) 297-7704 (614) 297-7705 New Sleep Patient Questionnaire Name _ Age Date General Medical History
Triage Information: 1. Duration of HPSJ Membership 2. Age 3. Fill history of Seasonal Allergy Medications
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Seasonal Allergy Medications LAST REVIEW: 5/28/2015 THERAPEUTIC CLASS: Rheumatologic/Immunologic REVIEW HISTORY: 5/15, 9/14
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
9220 Haven Avenue, Suite 101 Rancho Cucamonga, CA Tel: (909) Fax: (909) ALLERGY HISTORY
Name: Date of Birth: Date of Visit: Briefly describe the reason for your visit: How long have you had these problems? How frequently do you have them? NASAL SYMPTOMS ALLERGY HISTORY 1. I have the following
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
Frequent Ear Infections Past Present Have you had pressure equalization tubes? No Yes If yes, date(s): Ear Symptoms Past Present
BRIEFLY DESCRIBE THE REASON FOR THIS VISIT (what is your main concern or symptom?): CHECK SYMPTOMS YOU HAVE OR HAVE HAD: Nasal Symptoms Past Present Nasal congestion Runny nose Nasal discharge Postnasal
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
If you have asthma or use a rescue inhaler please answer the following questions:
Hernia (yr ), Tonsillectomy (yr ), Adenoidectomy (yr ), Bowel (yr ), Lung (yr ), Thyroid (yr ), Arthroscopy (yr ), Other Surgery (yr: ) Dates of Hospitalizations: What Hospital: Previous Tests Done/Approximate
NEW PATIENT QUESTIONNAIRE
Page1 Mala Bathija MD, PLLC 44000 West 12 Mile Road, Suite 212 Novi, MI 48377 14500 Northline Road Southgate,MI 48195 NEW PATIENT QUESTIONNAIRE Last Name First Name Phone # DOB Age Sex: M F Referring Physician
Weill Cornell Vascular
Weill Cornell Vascular Name: City: State: Zip Code: DOB: Age: Phone: (H) (W) (C) Indicate Primary: Email address: Religion: Ethnic Group: Race: Have you traveled to Africa (specifically (Guinea, Liberia,