Patient Information - Child
(17 and under)
Demographic Info
Last Name
First Name
MI
Gender
Male
Female
Date of Birth
Soc. Sec. No.
Marital Status
Married
Single
Divorced
Widowed
Address
City
State
Zip
Occupation
Race
Ethnicity
Hispanic/Latino
Other
Preferred Language
English
Spanish
Other
Phone
Email Address
Parent's Email
Mother's Last Name
First Name
Mother's Address (if different)
City
State
Zip
Home Phone
Cell Phone
Date of Birth
Soc. Sec. No.
Father's Last Name
First Name
Father's Address (if different)
City
State
Zip
Home Phone
Cell Phone
Date of Birth
Soc. Sec. No.
Referring Doctor's
Last Name
First Name
Phone
Family Doctor's
Last Name
First Name
Phone
Has the child or anyone in the family been seen at our office before?
Yes
No
If yes, who?
What is the reason for your visit
Pharmacy Name
Address
City
State
Zip
If the patient is a child under the age of 18, please list the guardians (who must be legal adults age 18 or older), other than the parents, who can seek medical treatment for this patient at our facility
Last Name
First Name
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Insurance Info
Do you have healthcare insurance
Yes
No
Primary Insurance
Co-pay Amount
Policy or ID No.
Group No.
Subscriber Name
Address
(if different from above)
City
State
Zip
Subscriber SSN
Subscriber DOB
Subscriber Employer
Employer Phone
Employer Address
City
State
Zip
Do you have secondary insurance
Yes
No
Secondary Insurance
Co-pay Amount
Policy or ID No.
Group No.
Subscriber Name
Address
(if different from above)
City
State
Zip
Subscriber SSN
Subscriber DOB
Subscriber Employer
Employer Phone
Employer Address
City
State
Zip
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 child's 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 my dependents. 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
Medication Name
Strength (mg)
Times/day
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Are you allergic to any medication?
Yes
No
Medication Name
Reaction
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Have you had allergy testing?
Yes
No
Date -
Skin Test?
Yes
No
Blood Test?
Yes
No
Allergy Shots?
Yes
No
List all food, contact and inhalant allergies
Substance Name
Reaction
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Past Medical History
Do you have any of the following?
Yes
No
Diabetes1
Asthma
Depression
ThyroidNodule
Reflux
HIV
Diabetes2
TB
Anxiety
Thyroid
Bleeding
Aids
Cholesterol
Apnea
KidneyStone
Ulcer
Hepatitis
type
HBP
NasalAllergies
Cancer History
type
year diagnosed
Height
Weight
Is there a chance you are currently pregnant?
Yes
No
N/A
Other medical conditions or problems
Condition or problem
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Have you or anyone in your family been seen by one of our physicians in the past?
Yes
No
Last Name
First Name
Physician Last Name
Physician First Name
Have you had a colonoscopy?
Yes
No
Date
Have you had a pneumonia vaccination?
Yes
No
Date
Have you had a influenza (flu) vaccination?
Yes
No
Date
Have you had a mammogram?
Yes
No
Date
Have you had a pap screening?
Yes
No
Date
Surgical Procedures/Reason for Hospitalization
Year
Procedure
Reason
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Have you had any serious injuries, such as head trauma, broken bones, concussion, or loss of consciousness?
Yes
No
Type of injury
Date
Do you or any member of your family have a history of problems with anesthesia?
Yes
No
Please explain
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?
Type
Family Member
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Social History
Do you smoke?
Yes
No
Past
Amount per day
Number of years
When did you quit?
How much did you smoke a day?
Do you consume alcohol?
Yes
No
Please indicate amount and frequency
Is there a personal history of substance abuse?
Yes
No
Please explain
If the patient is a minor, is he or she exposed to cigarette smoke?
Yes
No
Do you CURRENTLY have any of the following?
Yes
No
Please check the medical symptom(s) below:
Blurred Vision
Dizziness
Nosebleeds
Hoarseness
Cough
Stomach Pain
Vomiting
Chills
Difficulty or
painful urination
Double Vision
Ringing in Ears
Postnasal Drainage
Snoring
Wheezing
Nausea
Diarrhea
Sweats
Ear Drainage
Ear Pain
Facial Pressure
Chest Pain
Neck Mass
Headaches
Seizures
Memory Loss
Hearing Loss
Nasal Congestion
Sore Throats
Irregular Heartbeat
Shortness of Breath
Benign Skin Lesion
Malignant Skin Lesion
Sudden Weight Change
Is there a personal history of hearing loss?
Yes
No
When was your hearing evaluated last?
Where?
Do you wear hearing aids?
Yes
No
How old are your current aid(s)?
Medical Information Release
People authorized to receive medical info
I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. This information may be released to:
Last Name
First Name
Relationship
Phone/Cell
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Information is not to be released to anyone
Messages
- Please call
My home
My work
My cell
If unable to reach me
You may leave a detailed message
Leave a message asking me to return your call
Responsible Party 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.
Last Name
First Name
Relationship
Phone
Date