Referring PCP  
        Other Physicians Seen

SYMPTOMS                                         ALLERGIES                         REACTION

Voice change Difficulty Swallowing Nasal breathing problem Apnea Snoring Weight Loss <15% Weight gain >15% Bleeding Headaches Heartburn Bite/TMJ problem             Penicillin Erythromycin Sulfa Tetracycline Narcotics Local anesthetic Aspirin Iodine/Shellfish Pollen Other            Rash Shock Arthritis Asthma Other                         

PAST ILLNESS                                   SURGERY TYPE                  FAMILY HISTORY 

Hepatitis / Jaundice Cancer TB Ulcers Reflux / GERD Kidney disease / Nephritis Heart attack / MI Heart murmer / MVP Rhuematic fever Hypertension Stroke / TIA Diabetes Siezures Noise exposure Cancer HIV / ARC /AIDS Hay fever / allergic rhiitis Head Injury Radiation Therapy            T / A Nasal Sinus / FESS Cosmetic Thyroid Cancer Other               Diabetes Bleeding Heart disease Allergy Asthma Anesthesic problems

MEDICATION
Analgesics         Hormones              Antibiotics               Cardiovascular                   Others
Aspirin Advil Motrin Bufferin Anacin Nuprin NSAIDS Codeine Vicodan Other   Estrogens Premarin Thyroid Birth Control Insulin    Penicillin Amoxicillin Augmentin Cipro Biaxin Zithromax Tetracycline Doxycycline    Diruetics Anti-hypertensives Blood Thinners Coumadin    Sleepers Vitamins Herbs

HABITS

Do You Smoke Now? Yes No
If Yes, how many daily? less than 5/day 5-10/day 10-20/day 20-40/day How many years? one year less than 5 years less than 10 years 10-20 years
If No, when did you quit? today less than 1 week ago 1-5 years ago more than 5 years Why did you quit? bad habit health problems MD advice

Alcohol usage Yes No      What Beer Wine Liquor            Amount one/day 5-10/day 1 oz per day 2 oz per day

Reason for today's visit: _____________________________________________________________________________