San Francisco Ear Nose & Throat Medical Group, Inc

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1 SF ENT San Francisco Ear Nose & Throat Medical Group, Inc Adult & Pediatric Otolaryngology Hearing Disorders Endoscopic Sinus Surgery Head & Neck Surgery Thomas L. Engel, M.D. Vanessa R. Erickson, M.D. Daniel F. Hartman, M.D. Aditi H. Mandpe, M.D. Robert A. Mickel, M.D., Ph.D. Scott D. Stone Practice Administrator Dear New Patient, Hello and welcome to our practice! The San Francisco Ear, Nose and Throat Medical Group is a group of five Otolaryngologist/Head and Neck Surgeons or ENT doctors, as they are often called. We strive to exceed your expectations for high-quality and timely care. As a group, we have expertise in most areas of this specialty. We care for a wide variety of problems in adults and children including hearing loss, ear infection, balance disorders, nasal deformity, nasal and sinus diseases, throat disorders, voice disorders, snoring and sleep apnea, thyroid and parathyroid disorders and head and neck cancer. One of our physicians also distributes hearing aids. Our office is located in Suite 505 at 3838 California Street next to the California Campus of the California Pacific Medical Center. We are located on the north side of the street between Cherry and Arguello Streets. Please print the included three page patient registration and health information form and bring the completed form to your first visit. For your first visit, please plan on arriving 15 minutes prior to your appointment to complete your registration. Please also bring insurance information and referral information if it is required by your insurance company/medical group. Our doctors are providers for many Health Maintenance Organizations (HMOs) through the Brown and Toland Medical Group. We also contract with many preferred provider organizations (PPOs.) Please confirm that we are contracted providers with your insurance company as our patients have the final financial responsibility for the services that we provide. We will be pleased to see you even if we are not participating providers with your insurance company. If this is the case, your insurance company is likely to pay some of the cost of your visit. If we are not a participating provider with your insurance company, payment is expected at the time of your visit and we will courtesy bill your insurance company to help you collect the balance due from them. We look forward to meeting you and are delighted that you have chosen to come to our office. We welcome any comments that you may have. Sincerely, Scott Stone Practice Administrator 3838 California Street, Suite 505, San Francisco, CA Telephone Fax

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3 PATIENT NAME: DATE OF BIRTH: DATE: MEDICAL HISTORY: Do you have or have you ever had any of the following medical problems? If yes, please check the box next to the problem. Anemia Asthma Emphysema Pneumonia/Bronchitis Bleeding/Blood disorder Cancer (type ) Diabetes Thyroid Disease Epilepsy/Seizures Stroke High blood pressure Heart problems Stomach ulcer/acid reflux Liver disease Hepatitis High cholesterol or lipids Kidney disease Tuberculosis HIV/AIDS Other Immune disorder Arthritis Depression Glaucoma Other Please list all surgeries: 1. Date 2. Date 3. Date Have you ever had problems with anesthesia? NO YES Explain: Please list all Hospitalizations and serious illnesses: 1. Date 2. Date 3. Date MEDICATIONS: If you don t take any medications, check this box: Prescription medications Over the counter medications: (Aspirin, Ibuprofen, Naproxen) Herbs, Natural medications MEDICATION ALLERGIES: If you don t have any allergies to medications, check this box: Medication & Reaction Medication & Reaction FAMILY HISTORY: Do you have a family history of major medical problems? If yes, check the box below: Cancer (type ) Diabetes Heart disease Allergies Unexpected, early hearing loss Other Revised March 2010

4 PATIENT NAME: DATE OF BIRTH: DATE: SOCIAL HISTORY: Do you or did you drink alcohol? NO YES Amount of drinks a day? If you quit, when? Do you or did you use tobacco? NO YES Cigarettes: packs per day How many years If quit, when? Other tobacco: type amount a day if quit, when? Do you or did you use recreational drugs? NO YES REVIEW OF SYSTEMS Place a check next to any illness, symptoms or problems you have had in the past month: CONSTITUTIONAL SYMPTOMS Good general health Recent weight change Loss of appetite Fatigue Fever/sweats EYES Eye disease or injury Eye glasses or contact lenses Blurred or double vision Glaucoma EARS/NOSE/MOUTH/THROAT Hearing loss Hearing noises in your ear Earaches or drainage Nosebleeds Trouble swallowing Bleeding gums Sore throat Snoring Voice changes MUSCULOSKELETAL Joint pain/ stiffness Muscle pain/ cramps/ weakness Back pain CARDIOVASCULAR Chest pain/ angina Palpitations Shortness of breath Swelling of feet, ankles, or hands Murmur RESPIRATORY Cough Spitting up blood Shortness of breath Wheezing GASTROINTESTINAL Problems with bowel movements Nausea or vomiting Rectal bleeding or blood in stool Abdominal pain or heartburn GENITOURINARY Flank pain Problems with urination Blood in urine Kidney stone NEUROLOGICAL Headaches Numbness or tingling sensations Tremors Head injury HEMATOLOGIC/LYMPHATIC Slow to heal after cuts Bleeding or bruising tendency Phlebitis or blood clots Past blood transfusion OTHER SYMPTOMS Memory loss or confusion Nervousness Depression Insomnia Current Height: Current Weight: Completed by: Relationship Date Reviewed by Clinician: Date Revised March 2010

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