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ADULT REGISTRATION FORM

Maryland ENT logo

2415 Musgrove Road, Suite 203
Silver Spring, Maryland 20904
(301) 989-2300
 
 
Adult Patient Information
Gender*
 
At least one phone number below is required*
Allergies to any Medications?*
 
Insurance Information
Do you have Healthcare Insurance?*
Authorization

I hereby authorize Maryland ENT Associates to apply for benefits on my behalf for services rendered to me and request that payment be made by my insurance company and that payments be sent directly to Maryland ENT Associates. I understand that it is the policy of Maryland ENT Associates to only bill my insurance company if they participate with that company, and if they do not, it will be my responsibility to bill my insurance company for reimbursement of my expenses. I further authorize Maryland ENT Associates to release necessary information to my insurance company, or to the Insurance Commissioner of MD as necessary to obtain payment for my services.

I understand that this in no way relieves me of my primary responsibility to pay for services rendered to me, and if my account is turned over to an attorney for collection, I agree to pay any collection and reasonable legal fees (40% is deemed reasonable) court costs, and other expenses incurred as a result of said collection, all actions having a venue of Montgomery County, MD, other venues notwithstanding. Further, I understand that there is a $25.00 fee for returned checks and $50.00 for missed appointments.

I certify that the information I have reported with regard to my insurance coverage is correct and I authorize the release of any information relating to any claim for benefits, in order to process any claim for benefits. Furthermore, I permit a copy of this authorization to be used in place of the original. I may revoke this authorization at any time in writing.

I understand that the information contained on this form will be used to process my billing and/or insurance claims for service received in this office. It is important to be sure that this information is correct prior to receiving care to prevent problems for the patient in the future.

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 

 

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ADULT MEDICAL HISTORY

 
Adult Patient Information
Demographics
Gender*
 
Ethnicity
 
Marital Status
     
General Health History
Are you ALLERGIC to any medications or Latex?*
 
Do you use blood thinners? Ex: aspirin, Coumadin/Warfarin, Plavix, Pradaxa?*
 
Do you use any herbal, alternative medications, or diet pills?*
 
Are you CURRENTLY taking any medication (prescription or non-prescription)?*
 
Health Problems
Please list any current or past health problems:
Cardiac (eg: cholesterol, pacemaker, heart attack*)
 
Hypertension or high blood pressure*
 
Diabetes or uncontrolled sugar*
 
Thyroid (eg: nodules, goiter, high or low function*)
 
Allergies or hay fever*
 
Hearing loss, ringing, or other hearing changes*
 
Sinus or nasal problems previously diagnosed*
 
Neurologic (eg: migraine, multiple sclerosis)*
 
Stroke or TIA*
 
Balance problems, BPPV, vertigo or dizziness*
 
Pulmonary (eg: asthma, COPD, bronchitis)*
 
Sleep apnea or CPAP use*
 
Gastrointestinal (eg: acid reflux disease, IBS)*
 
Psychiatric (eg: depression, anxiety, bipolar)*
 
Cancer*
 
Bleeding or blood clotting problems*
 
Endocrine (eg: Cushing, PCOS)*
 
Other (eg: arthritis, autoimmune disease)*
 
Do you use tobacco?*
 
Any past tobacco use?*
 
Do you drink alcohol?*
 
Any weight changes >10 lbs. this year?*
 
Do you exercise?*
 
Surgical History
Previous Head/Neck/Sinus or Ear surgeries?*
 
Tonsils Removed?*   
 
Adenoids Removed?*   
 
Please list ALL additional surgeries below:

 

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ACKNOWLEDGEMENT of RECEIPT

 
of Notice of Privacy Practices

Click here to view our Notice of Privacy Practices.

I have received the Notice of Privacy Practices from Maryland ENT Associates, effective date 9/23/2013

Patient/Legal Representative Name
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Disclosure to Family/Friends

 

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SLEEP QUESTIONNAIRE

 
Epworth Sleepiness Scale

The Epworth sleepiness scale is used to help you Identify your own level of daytime sleepiness. Use the following scale to choose the most appropriate number for each situation: 0= Would never doze 1= Slight chance of dozing 2= Moderate chance of dozing 3= High Chance of dozing

Total score of 10 or more suggests wake-time sleepiness that may require a sleep evaluation to determine whether you are obtaining enough sleep or if you have an underlying sleep disorder. If your score is 10 or more please share this with your doctor.
Sleep Apnea Risk Questionnaire
Do you have a history of snoring?*



Have you ever been told that you have “pauses” in breathing during sleep?*



Are you overweight?*



Epworth score from above:*



Does your medical history include:







Your apnea risk score suggests:
 
5-9
Discuss complaints with your doctor
10-14
A consultation with a sleep specialist is recommended
15-19
Sleep consultation and sleep study is recommended
20+
Significant risk of sleep apnea – sleep study should be scheduled

This “Apnea Risk Score” is not intended to rule out the possibility of a sleep-related disorder. If you have concerns related to your sleep you should discuss them with your doctor.
 
Patient/Legal Representative Name

 

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WELLNESS UPDATE

 
Symptoms
Do you experience any of these symptoms?







How often do you experience these symptoms?



Do you take prescription or over-the-counter (OTC) medications for the management of your allergy symptoms?
 
Please indicate below symptoms/conditions you’ve experienced during the last 1 – 2 years








NOTE: When finished, please click the Submit Registration button below to send your form securely to our office. If you need to print a copy, please do so before clicking Submit.

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