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Coastal ENT Medical Group- History Form MEDICAL HISTORY Referral PCP_____________________________________ Have you had any of the following? Please check where appropriate. SYMPTOMS ALLERGIES REACTION Voice change Penicillin/Amoxicillin_______________________________________ Difficulty swallowing Erythromycin /Biaxin ______________________________________ Nasal breathing problem Sulfa / Septra ______________________________________ Snoring / Apnea Tetracycline/Doxy ______________________________________ Weight Loss / Gain > 15% Narcotics ______________________________________ Bleeding Local Anesthetic ______________________________________ Headaches Pollens ______________________________________ Heartburn / reflux Aspirin /NSAIDS ______________________________________ Bite / dental problem Iodine / Shellfish ______________________________________ Other ______________________________________ PAST ILLNESS SURGERY TYPE / DATES Hepatitis / Jaundice Tonsil / Adenoid__________________________________________ Cancer Nose / Sinus ____________________________________________ Tuberculosis / TB Cosmetic_______________________________________________ Ulcers / Reflux Thyroid ________________________________________________ Kidney Disease / Nephritis Cancer _________________________________________________ Heart Attack / MI Other than above________________________________________ Heart Murmur / MVP / Rheumatic fever _________________________________________________________ Hypertension Stoke / TIA Diabetes Seizures DO THE FOLLOWING RUN IN YOUR FAMILY? Noise Exposure Cancer Anesthesia problems Radiation Therapy / Radium / Cobalt Diabetes Allergies HIV / AIDS / ARC Bleeding Heart disease Hay Fever / Allergic Rhinitis Other_________________________________________________ Asthma Head Injury Do You Smoke Now? Yes No Never have If Yes, how many daily? ________How many years?_______ If No, when did you quit? _______ _____Why did you quit? ______________________________ Alcohol usage No Yes Amount_____________ PLEASE SPECIFY AND CIRCLE DAILY MEDICATIONS AND AMOUNTS: Aspirin / Bufferin / Anacin / Nuprin / Advil / Motrin / NSAIDS.________________________________________________ Premarin / Thyroid / Birth Control Pills__________________________________________________________________ Antibiotics________________________________________________________________________________________ Vitamins, Herbs and Fish Oils________________________________________________________________________ Diuretics / Insulin / Blood Thinners ____________________________________________________________________ Sleeping Pills / Pain Killers __________________________________________________________________________ Anti-Hypertensives_________________________________________________________________________________ Other____________________________________________________________________________________________ Reason for today's visit: ___________________________________________________________________________ ________________________________________________________________________________________________
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