Ear Surgery Form

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PRE-VISIT FORM

Complete this form and bring it with you to your first doctor’s visit.

Patient Information Patient Name: Today’s Date: Referring Physician: Family Physician: Date of Birth: Age:  Height:  ft  in Weight:  Gender:  female male Marital Status:  single  married  widowed  divorced Number of Children: Personal Health History What is the reason for this visit? Have you ever had a heart problem?  Yes  No If yes, please explain: Do you have or have you ever had any of the following? Rheumatic fever Date:  Heart murmur Date:  Heart attack Date:  Chest pain/pressure Date:  Heart failure Date:  Rapid heart beat or irregular pulse Date:  Light-headedness Date:  Dizziness Date:  Fainting Date:  Swelling of the ankles Date:  Pain in calf muscles when walking Date:  Congestive heart failure Date:  Shortness of breath Date:  Have you ever had any of the following heart studies?  EKG  Echocardiogram  24 Hour monitor  Cardiac Catheterization  Treadmill  Chest x-ray Other:  Have you ever had a reaction to the dye used in certain cardiac x-rays?  Yes  No  I have never had this type of x-ray Do you have any allergies to medication?  Yes  No If yes, which medications: Do you currently smoke?  Yes No Pack per day: Number of years: Have you ever smoked?  Yes No Date stoppped: Do you have elevated cholesterol?  Yes No Last checked: Do you have high blood pressure?  Yes No How many years: Do you drink alcoholic beverages?  Yes No How much each day: Are you generally stressed?  Yes No Do you drink beverages containing caffeine?  Yes No How much: Do you excerise?  Yes No If yes, what is your excerise routine: Are you following a special diet?  Yes No If yes, please describe: Occupation: Describe your job tasks: Are you retired?  Yes  No Date  Are you disabled?  Yes  No Date  If yes, describe your disability: Describe any surgeries you have had: Surgery Year Please check any other health condition you have or have had in the past: Scarlet fever Menstrual dysfunction Anxiety Kidney disease Emphysema Breathing problems Ulcer Venereal disease Anemia Sexual dysfunction Arthritis Asthma Stomach or bowel disorder Allergies/Hay fever Fatigue Gout Urinary problem Thyroid disease Rheumatic fever Diabetes/high blood sugar Depression Migraine headache Constipation Liver disease Cancer  Other  Family History Do you have a history of heart disease in your family?  Yes  No If yes, indicate relation and age problems started? Family Member(s) Alive Deceased Current Age or Age at death Cause of Death Mother Father Sister(s) Brother(s)