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

Similar documents
Creve Coeur Family Medicine, LLC

Patient Intake Form for Allegany Ear, Nose, & Throat

Office Policy for New Patients

New Patient Questionnaire

*521634* Sleep History Questionnaire. Name of primary care doctor:

Patient History Form

New Sleep Patient Questionnaire. Name Age Date. General Medical History 1. Please list any surgeries you have had and their approximate dates:

Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician:

Allina Health United Lung and Sleep Clinic

Please print neatly and fill out every item as accurately as possible. Ask a staff member if you require assistance in filling out this form.

Medical History Questionnaire

New Pulmonary Patient Questionnaire. Name Age Date. General Medical History

NEW PATIENT INTAKE FORM

NEW PATIENT INFORMATION FORM

1960 FP CENTER FOR SLEEP DISORDERS

DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM

Balance and dizziness questionnaire

MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE. Name: Date of Birth: / / Age: Sex: Address: City: Zip:

HEALTH HISTORY QUESTIONNAIRE

SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:

Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother

Comprehensive Allergy and Asthma Care Center. New Patient Questionnaire. Patient Name: Age: DOB: Sex: M F

PLEASE INDICATE ANY OF THE FOLLOWING YOU ARE NOW EXPERIENCING:

Patient Medical History Form Pre-Surgical Bleeding History Questionnaire Name:

A B O U T Y O U D E N T A L I N F O R M A T I O N

Headache Follow-up Visit Form

I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.

PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.

Emotional Relationships Social Life Sexually Recreation

*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

Medical Questionnaire

HD CLINIC MEDICAL HISTORY FORM

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE

Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)

Sleep History Questionnaire

Comprehensive History, Consult, and Evaluation Form

The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION

Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:

General Questionnaire

San Francisco Ear Nose & Throat Medical Group, Inc

Inner Balance Acupuncture

Patient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.

Name. Date of Birth. Primary Care Doctor? Who is the Doctor that referred you to us? Name of person completing this form?

Parkinson Disease and Movement Disorder Institute

PLEASE DO NOT WEAR FRAGRANCES

NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.

Frequent Ear Infections Past Present Have you had pressure equalization tubes? No Yes If yes, date(s): Ear Symptoms Past Present

1 I *********IF YOU ARE NOT ON ALLERGY SHOTS PLEASE SKIP THIS SECTION AND MOVE TO PAGE 2********* NAME: AGE: ---- ID (For Office Use Only):

Patient Health Questionnaire

Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:

The Socioeconomic Cost of Chronic Rhinosinusitis (SoCCoR) Study

Head and Chest. Back and Stomach. Muscles and Joints. Skin. General Symptoms. Women s Health

Medical History Questionnaire

PRIMARY CARE (719)

Welcome to the Koala Center for Sleep Disorders

Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

Medical History Form

PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)

Date of Visit / / Date of Birth / / Age

Patient Adult Information History

ENT & Allergy Specialists of VA Registration Form

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS

Please complete and return to the office prior to your appointment.

Mary Maier, MD Board Certified Allergist and Immunologist 2011 NW Myhre Place, Silverdale, WA (360)

The Socioeconomic Cost of Chronic Rhinosinusitis (SoCCoR) Study

Health History. Tests and Procedures: Test: Date: Location: Provider: Abnormal: Results/Notes: Monthly self breast exam. Last mammogram (female)

MEDICAL DATA SHEET For Patients 18 years of age and older

Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY

I will be contacting you with the day, time and location of the scheduled procedure.

3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication

DIVISION OF CARDIOLOGY

Who is filling out this intake form? Self Spouse Parent Guardian

Charleston Hematology Oncology Associates, PA Medical History

Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

RHEUMATOLOGY PATIENT HISTORY FORM

STEPS. How to Get Well When You re Sick or Hurt. Nancy Lobb illustrated by David Strauch. Third Edition

MEDICAL QUESTIONNAIRE (male)

1. Instructions: Please answer the questions as they relate to the person being evaluated. Bring this form with you to your first appointment.

Name: Date: Street Address: Referring Physician: How long have you had your current problem?

Medical Questionnaire

BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:

In case of an urgent concern or emergency, call 911 or go to the nearest emergency department right away.

NEW PATIENT HEALTH HISTORY

PATIENT MEDICAL HISTORY PATIENT INFORMATION

9220 Haven Avenue, Suite 101 Rancho Cucamonga, CA Tel: (909) Fax: (909) ALLERGY HISTORY

New Patient Registration

BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM

Chronic Sinusitis. Acute Sinusitis. Sinusitis. Anatomy of the Paranasal Sinuses. Sinusitis. Medical Topics - Sinusitis

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)

medical questionnaire Date: Day Month Year

The RBE Toxicity Quiz: How Full Is Your Rain Barrel?

MRN: T C D PATIENT INFORMATION

Transcription:

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. 0 1 2 3 4 5...1 2 3 4 Runny nose....0 1 2 3 4 5...1 2 3 4 Sneezing.0 1 2 3 4 5...1 2 3 4 Decreased sense of smell or taste.. 0 1 2 3 4 5......1 2 3 4 Postnasal discharge..0 1 2 3 4 5....1 2 3 4 Thick nasal discharge/debris..0 1 2 3 4 5....1 2 3 4 Bloody nose.0 1 2 3 4 5....1 2 3 4 2. Eye Symptoms Itchy, watery eyes.0 1 2 3 4 5...1 2 3 4 Swollen, sore eyes.0 1 2 3 4 5...1 2 3 4

3. Sleep MAGNITUDE IMPORTANCE Difficulty getting to sleep 0 1 2 3 4 5....1 2 3 4 Wake up during the night 0 1 2 3 4 5....1 2 3 4 Lack of a good night s sleep..0 1 2 3 4 5....1 2 3 4 Wake up tired...0 1 2 3 4 5....1 2 3 4 4. General Symptoms Fatigue/worn out..0 1 2 3 4 5......1 2 3 4 Reduced productivity....0 1 2 3 4 5....1 2 3 4 Poor concentration 0 1 2 3 4 5.....1 2 3 4 Headache....0 1 2 3 4 5...1 2 3 4 Facial pain/pressure....0 1 2 3 4 5...1 2 3 4 Cough.....0 1 2 3 4 5...1 2 3 4 Short of breath....0 1 2 3 4 5...1 2 3 4 5. Practical Problems Need to rub nose/eyes....0 1 2 3 4 5...1 2 3 4 Need to blow nose repeatedly.0 1 2 3 4 5...1 2 3 4 Bad Breath...0 1 2 3 4 5...1 2 3 4 6. 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

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

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

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?

THANK YOU FOR FILLING OUT THIS FORM COMPLETELY

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback