New Patient and Long Term Follow Up Patient Information
Name  
Age  
Primary Care Doctor  
Drug Allergy  
Duration of Symptoms  
Chief Complaint
HPI


Please answer the following to update our records.
 
Past Medical History



















Other  


Most Recent Hospitalization:
 
Date  
Reason  
Past Operations:(Please list the most recent First and the year preformed)
Current Medications  
Have you ever been Allergy Tested?
Are you on Allergy Shots?
Have you been on shots in the past?
Do you have an allergy to Latex?
Do you take asprin?
Do you take blood thinner?
Are you pregnant?
Does Someone in your family have the same medical problem?
Who  


Social History
 
Occupation  
Is your child in daycare?


Tobacco History






Alcohol History
Do you drink alcohol?
Have you ever been diagnosed with a drug or alcohol dependancy?


Any information provided on this web site should not be considered medical advice or a
substitute for a consultation with a physician. If you have a medical problem,
contact your local physician for diagnosis and treatment.

© 2005 Carolina Ear, Nose & Throat, Head and Neck Surgery Center