Ear Institute of Chicago

 

11 Salt Creek Lane , Suite 101

Hinsdale, IL 60521

 

800 Biesterfield Road, Ste 4001

Elk Grove Village, IL 60007

          

            

PATIENT HEALTH HISTORY

 

Patient Name:__________________________________________Date of Birth:__________________

CHIEF CONCERN

 

Reason for today's visit:_______________________________________________________________

PAST MEDICAL HISTORY

 

Please list any prior major illnesses and/or injuries:_________________________________________

 

___________________________________________________________________________________

 

___________________________________________________________________________________

 

SURGERIES/HOSPITALIZATIONS

YEAR

 

 

 

 

 

 

   

 

MEDICATIONS (List Name, dosage and frequency)

1.

5.

9.

2.

6.

10.

3.

7.

11.

4.

8.

12.


DRUG ALLERGIES :________________________________________________________________

 

FAMILY HISTORY

(List family member and history of hearing loss, dizziness, migraine or acoustic tumor)

 

 

 

 

 

 

 

   

 

SOCIAL HISTORY

 

Occupation:_________________________________________________________________________

History of smoking?: No ____ Yes ____ If yes, what type and for how long?____________________

History of alcohol use: No_____ Yes____ How often?______________________________________


REVIEW OF SYSTEMS (Please circle all items that you have had problems with)

Allergic/Immunologic:

Food Allergies

Immunologic Disorder(s):__________

Inhalant (nasal) Allergies

 

Cardiovascular:

Chest pain or angina

Heart Murmur

Irregular Pulse

Leg Pain/Cramping While

Walking

Palpitations

Swelling in Hands and/or Feet

 

Constitutional:

Excessive Fatigue

Fever

Night Sweats

Weight Loss

 

Dermatologic (Skin):

Skin Cancer

Skin Disease

 

Endocrine:

Excessive Thirst

Excessive Urination

Hormone Problems

Increased Appetite

Ear, Nose, Throat:

Dizziness:

Floating Sensation

Lightheadedness

Spinning

Unsteadiness

Ear Drainage

Ear Fullness

Ear Pain

Hearing Loss

Inability to Smell

Mouth Sores

Nasal Congestion

Nasal Drainage

Nose Bleeds

Ringing (Noise) in the Ear(s):

Left___ Right___ Both___

Sore Throat

 

Neurological:

Difficulty with Speech

Disorientation

Facial Numbness

Facial Twitching

Facial Weakness

Fainting Spells or Blackouts

Inability to Concentrate

Memory Problems

Migraine Headaches

Problems with Coordination

Seizures

Tingling of Feet

Tingling of Hands

 

Ob/Gynecology:

Breast Cancer

Cervical Cancer

Preganancy

Uterine Cancer

 

Ophthalmology (Eyes):

Blurred Vision

Diminished Vision

Double Vision

Eye Inflammation

 

 

Gastroenterology:

Abdominal Pain

Change in Bowel Habits

Colon Cancer

Nausea

Ulcers or Gastritis

Vomiting

 

Hematologic/Lymphatic:

Anemia

Bleeding Tendency

Hemophilia

 

Musculoskeletal:

Arthritis

Back Pain

Broken Bones

Joint Pain

Joint Swelling

 

Psychiatric:

Anxiety

Depression

Sleep Disturbance

Suicidal Thoughts

 

Respiratory:

Chronic Cough

Lung Cancer

Shortness of Breath

Wheezing

 

Urology:

Blood in your Urine

Dialysis

Difficulty Urinating

Kidney Stones

Prostate Cancer

The above information is accurate to the best of my knowledge:

Patient (or Guardian) Signature:_____________________________________________   Date:____________

 

The above information has been reviewed with the patient and is deemed correct:

Physician:_______________________________________________________________ Date:____________