Ear Institute of Chicago

 

 

11 Salt Creek Lane , Suite 101

Hinsdale, IL 60521

 

          

            

PATIENT HEALTH HISTORY

 

Patient Name:__________________________________________Date of Birth:__________________

 

CHIEF CONCERN

 

Reason for today's visit:_______________________________________________________________

 

PAST MEDICAL HISTORY (Please check all that apply)

 


Asthma

Diabetes

Heart Disease

High Blood Pressure



Acoustic Neuroma

Migraine Headache

Sarcoidosis

Seizures



Emphysema

Rheumatoid Arthritis

Thyroid Disorder

Cancer Type ______________

_____________________________

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 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:

Both___ Right___ Left___

 

Nasal Congestion

Nasal Drainage

 

Ringing (Noise) in the Ear(s):

Both___ Right___ Left___

 

 

Neurological:

Difficulty with Speech

Facial Numbness

Facial Twitching

Facial Weakness

Fainting Spells or Blackouts

Inability to Concentrate

Memory Problems

Tingling of Feet

Tingling of Hands

 

Ob/Gynecology:

Currently Preganancy

 

 

Ophthalmology (Eyes):

Diminished Vision

Double Vision

Eye Inflammation

 

 

Gastroenterology:

Abdominal Pain

Change in Bowel Habits

Nausea

Ulcers or Gastritis

Vomiting

 

Hematologic/Lymphatic:

Anemia

Bleeding Tendency

Hemophilia

 

Musculoskeletal:

Arthritis

Broken Bones

Joint Pain

Joint Swelling

 

Psychiatric:

Anxiety

Depression

Sleep Disturbance

Suicidal Thoughts

 

Respiratory:

Chronic Cough

Shortness of Breath

Wheezing

 

Urology:

Blood in your Urine

Dialysis

Difficulty Urinating

Kidney Stones

 

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

Patient (or Guardian) Signature:_____________________________________________   Date:____________