Patient Name: Date of Visit:

/ 1434 Chester Boulevard
Richmond, Indiana 47374
765-966-1600 tele / 765-962-9641 fax

PATIENT HISTORY – New Reid Ent/RPA Pt

 Dr. Bawa  Dr. Peers  Dr. Casselman  Amber Halley PA-C

Patient Name: Date of Visit:

Date of Birth: Age:

Height: Weight:

Reason for your office visit today:

When did your problem(s) start? / Days / Weeks / Months / Years
q  Sudden / q  Gradual / q  Ongoing / q  Since Birth / q  Unknown
How long does each episode last? / q  1 min / q  1-4 min / q  5-10 min / q  15-30 min / q  30-60 min
q  Hours / q  Days / q  Weeks / q  Months / q  Years
q  Intermittently / q  Constantly
What is the "severity" of your symptoms? / q  Mild / q  Moderate / q  Severe / q  Other
What is the current status? / q  Improving / q  Unchanged / q  Worsening / q  Resolved / q  Other
If you are having pain, describe pain: / q  Sharp / q  Dull / q  Burning / q  Throbbing
q  Aching / q  None

TESTING DONE TO EVALUATE CURRENT PROBLEM

q  CT Scan (type where/date )

q  MRI (type where/date )

q  Ultrasound (type where/date )

q  Other (type where/date )

MEDICATIONS

List current medications (including supplements) and dosage. / q  NONE
Medication / Dosage

ALLERGIES TO MEDICATIONS

List drug allergies & reactions. / q  NONE
q  Aspirin / q  Codeine / q  Penicillin
q  Sulfa / q  Latex
q  Other

MEDICAL CONDITIONS

Do you now have or have you ever had any of the following? / q  NONE
q  Alcoholism/Drug Addiction / q  Depression / q  Liver Disease
q  Allergies / q  Diabetes / q  Neurologic Disorder
q  Anemia / q  GERD/Reflux / q  Psychiatric Treatment
q  Arthritis / q  Heart Disease (type ) / q  Seizures/Epilepsy
q  Asthma / q  Hepatitis / q  Sleep Apnea
q  Bleeding Disorder / q  High Blood Pressure / q  Stroke
q  Cancer (type ) / q  Kidney Disorder / q  Thyroid Disease
q  COPD/Emphysema

Other problems not listed, recent hospitalization, or details about above listed problems:

PROCEDURE HISTORY

Check the procedure(s) you have had and write the date(s) performed. / q  NONE
Procedure / Date / Procedure / Date
q  Angioplasty/Stent / q  Hip Replacement
q  Appendectomy / q  Hysterectomy
q  Arthroscopic Knee / q  Knee Replacement
q  Back Surgery / q  LASIK
q  Carpal Tunnel / q  Pacemaker
q  Cataract / q  Sinus/Nasal Surgery
q  Colon Surgery / q  Thyroidectomy
q  Ear Tubes / q  Tonsillectomy
q  Gallbladder Removal / q  Adenoidectomy
q  Gastric Bypass / q  Tubal Ligation
q  Heart Bypass / q  Vasectomy
q  Hernia
q  Other (date/list)

FAMILY HISTORY

Relationship / Relationship
q  Cancer (type ) / q  Heart Disease
q  Diabetes / q  Kidney Disease
q  Hearing Loss / q  Liver Disease
q  Other

SOCIAL HISTORY

Smoking/Smokeless Tobacco History / q Current / q Former / (When did you quit? ) / q  Never

If yes, in what form & how much? How many years?

Do you drink alcohol? / q  Yes / q  No / q  Quit

If yes, in what form & how much?

PHARMACY INFORMATION

Name

Address

Phone

Mail Order Pharmacy

Signature of Patient or Guardian Date

Signature of Reid ENT Specialist Date

Revision Date: 05/26/16 Patient History Form - New RPA ENT Pt Page 3 of 3