ENT-Head & Neck Specialists

Patient Information

Demographic Info
Marital Status
Preferred Language
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Have you or any family member been seen at our office before?
Insurance Info
Do you have healthcare insurance
HIPAA: I have read and agree with the HIPAA Privacy information / Financial Policy: I have read and understand the financial policy.
I hereby authorize ENT Head & Neck Specialists to release and/or obtain information to/from insurance carriers, other physicians and/or medical facilities concerning my present illness/treatment and past medical history/treatment. I also hereby assign to the physicians of ENT Head & Neck Specialists all payments for medical services rendered to myself. I understand that I am responsible for any amount not covered by my insurance.
Medication Info
List all the medications (prescription/non-prescription) you are currently taking, including vitamins

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Are you allergic to any medication?
Have you had allergy testing?
Skin Test?
Blood Test?
Allergy Shots?
Past Medical History
Do you have any of the following?

Is there a chance you are currently pregnant?
Have you or anyone in your family been seen by one of our physicians in the past?
Have you had a colonoscopy?
Have you had a pneumonia vaccination?
Have you had a influenza (flu) vaccination?
Have you had a mammogram?
Have you had a pap screening?
Surgical Procedures/Reason for Hospitalization

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Have you had any serious injuries, such as head trauma, broken bones, concussion, or loss of consciousness?
Do you or any member of your family have a history of problems with anesthesia?
Family History
Has any family member had any of the following: Heart Disease, Diabetes, Bleeding Disorders / Problems, High Cholesterol, Allergies, Stroke, Asthma, High Blood Pressure, Hearing Loss, Cancer and what type?

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Social History
Do you smoke?
Do you consume alcohol?
Is there a personal history of substance abuse?
If the patient is a minor, is he or she exposed to cigarette smoke?
Do you CURRENTLY have any of the following?
Please check the medical symptom(s) below:

Is there a personal history of hearing loss?
Medical Information Release
Release Information

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