MI:
Social Security Number: Date of Birth: Age: Gender: Race: Martial Status Ethnicity: (Circle one):
Latino Non-Latino Other
City: State: Zip Code:
City: State: Zip Code:
Work Number:
Cell Number:
Date of Birth:
Date of Birth:
Signature: _________________________________________________ Date: _______________________________
6. Communication: I authorize the use of my email to contact me.
8. Multimedia Use: Yes, I consent to allowing AC to use any photographs or videos for multimedia use knowing all identifiers
No, I do NOT consent to allowing AC to use any photographs or videos for multimedia use despite the
physicians and/or medical facilities.
3. Assignment of Benefits: I request that payment of authorized insurance benefits be made on my behalf to AC.
4. Financial Responsibility: I understand that AC will file my insurance as a courtesy to me and that I remain responsible for
payment of co-pays, coinsurance, deductibles, non-covered services and any other charges not paid by insurance with 45 days.
5. Patient Rights: I have received a letter of patient rights.
of my identity will be removed prior to publication.
Authorizations, Medical Records Release, Assignment of Benefits1. Treatment Authorization: I authorize you to give me reasonable and proper medial care by today's standards.
2. Release of Information: I authorize release of my records to Ashford Clinic (AC) including HIV, psychiatric, drug/abuse records,
venereal disease and any other statutory protected disease, as necessary for continued medical care, to obtain insurance
reimbursement or to comply with utilization review. I authorize this office to obtain previous medical records from other
Employed by: Occupation: Can we contact you at work?
YES NO
Date: Last Name:
Language:
First Name:
Address (Street, Route, Apt. No, ect.)
Home Phone: Cell Number: Email Address:
EMPLOYER INFORMATION
Work Number: Employer's Address:
SPOUSE/GUARDIAN (If patient is a child, please give parent information)Name: Relationship to patient: Responsible for bill:
YES NO
Phone Number:
PHARMACY INFORMATION
Home Phone: Cell Number: Can we contact you at work?
YES NO
EMERGENCY CONTACTName: Relationship: Home Phone: Work Number:
removal of all of my identifiers.
Secondary Insurance Name: Subscriber Name: Relationship to patient:
Patient Registration Form Please Fill out Completely
Preferred Pharmacy: Phone Number: Pharmacy Location:
INSURANCE INFORMATION - Please provide your insurance card(s) at the time of visitPrimary Insurance Name: Subscriber Name: Relationship to patient:
PHYSICIAN INFORMATIONPrimary Care Physician Name: Phone Number:
Referring Physician Name:
Text
��� ��"���� ��"���"�� ���������� "��"� ���"�� "����������"
,:[G?O[�ZcO:N?�c34443334353364433467c#:[?cQ@c!GV[E�c8644663444c9c
&c]O>?UZ[:O>c[E:[cNacE?:K[EcGO@RVN:[GQOcGZcSVG_:[?c:O>c<QOB>?O[G:K�c &c]O>?UZ[:O>c[E:[c ZE@RU>c"KGOG<c "�c`QUJZc_?YcE:V>c[QcSUQ[?<[cNacSVF_:<ac:O>cSV?Z?X?c[E?c<QOB>?O[G:KH\acQ@c[E?cS?UZQO:KcE?:K[EcGO@RUN:[GQO�c
&c]O>?VZ[:O>c[E:[c "cN:ac]Z?c:O>c>GZ<KQZ?cNacS?UZQO:KcE?:K[EcGO@RUN:[GQOc,%&�c[QcE?KScSVQ_F>?cE?:K[Ec<:V?c[QcN?�c[QcE:O>K?c;GKKGODc:O>cS:aN?O[�c:O>c[Qc[:J?c<:V?cQ@c[E?cQ[E?VcE?:K[Ec<:V?cQS?U:[GQOZ�c &OcD?O?U:K�c[E?V?c GKKc;?cOQcQ[E?Vc]Z?Zc:O>c>GZ<KQZ]U?ZcQ@c[EGZcGO@QVN:[GQOc]OK?ZZc&c:][EQVGb?>cG[cGOc UG[GOD�c&c]O>?UZ[:O>c[E:[cZQN?[GN?Zc[E?cK:`cN:acU?T]GU?c[E?cU?K?:Z?cQ@c[EGZcGO@QVN:[GQOc`G[EQ][cNacS?UNGZZFQO�c0E?Z?cZG[]:[GQPZc:U?c_?Yc]O]Z]:K�c
"cE:Zc:c>?[:GK?>c>Q<]N?O[c<:KM?>c[E?c�*Q[G<?cQ@c,VG_:<ac,U:<[G<?Z��c &[c<QO[:GOZcNQV?cGO@QVN:[GQOc:;Q][c[E?cSQKG<G?Zc:O>cSU:<[G<?ZcSVQ[?<[GODcQ]VcS:[G?O[ZcSVG_:<a�c &c]O>?UZ[:O>c[E:[c'cE:_?c[E?cVIDE[c[QcV?:>c[E?c�*Q[G<?�c;?@RU?cZGDOGODc[EGZc:DU??N?O[�c "cN:ac]S>:[?c[EGZc�*Q[G<?cQ@c,VG_:<ac,U:<[G<?Z�c:[c:Oac[GN?�c &@c&c:ZJ c "c`GKKcSVQ_G>?cN?c G[Ec[E?cNQZ[c<]VV?O[c�*Q[H<?cQ@c,VG_:<ac,V:<[G<?Z��c2O>?Uc[E?c[?VNZcQ@c[EGZc<QOZ?O[�c&c<:Oc:ZJc "c[QcKGNG[cEQ`cNacS?VZQO:KcE?:K[EcGOCVN:[GQOcGZc]Z?>cQVc>GZ<KQZ?>c[Qc<:UYcQ]Vc[U?:[N?O[�cS:aN?O[cQVcE?:K[Ec<:V?cQS[GQOZ�c &c]O>?UZ[:O>c[E:[c "c>Q?ZcOQ[cE:_?c[Qc:DV??c[QcNacV?T]?Z[�c &@c "c>Q?Zc:DV??c[QcNacU?T]?Z[�c&c]O>?VZ[:O>c[E:[c[E?ac Q]K>c@QKKQ`c[E?c:DV??>cKGNG[Z�c
+]Vc*Q[G<?cQ@c,UG_:<ac,U:<[G<?ZcZ[:[?Zc[E:[c`?cN:ac>GZ<KQZ?caQ]Uc,%&c[QcQ[E?UZc`EQcN:ac:ZZGZ[cGOcaQ]Vc<:V?�cZ]<Ec:ZcaQ]VcZSQ]Z?�c<EGK>V?O�cS:V?O[Z�cQVc<:U?DG_?V�c �� � "����"��"�����"� � ��"��"�� ��� ��"����"����"� "� "������! �"��"�������" ���"� ����"�� "��"��"����"� "��"� � � "� ����"� ������"
��*Q�c&c>QcOQ[c:][EQWGb?cV?K?:Z?cQ@cGO@QVN:[GQOc[Qc@:NGKa�<:V?DG_?VZ�c &@caQ]c GZEc[Qc-$/1.("0c]Z?�>GZ<KQZ]V?cGOcQ[E?V`:aZ�cSK?:Z?cU?T]?Z[c:c@QUN�
&cN:ac<:O<?Kc[EGZc<QOZ?O[cGOc UG[GODc:[c:Oac[GN?c;ac UG[GOD�cZGDOGOD�c:O>c>:[GODc:cK?[[?Vc[Qc "�c 0E?cK?[[?VcN]Z[cZ:ac[E:[c&c :O[c[QcU?_QJ?cNac<QOZ?O[c[Qc:][EQUGb?c[E?c]Z?c:O>c>FZ<KQZ^U?cQ@cNacS?UZQO:KcE?:K[EcGOARUN:[GQOc@RUc[U?:[N?O[�cS:aN?O[c:O>cE?:K[Ec<:V?cQS?U:[GQOZ�c &@c&cU?_QJ?c[EGZc<QPZ?O[�c "c>Q?ZcOQ[cE:_?c[QcSVQ_G>?c:Oac@]V[E?UcE?:K[Ec<:U?cZ?XG<?Zc[QcN?�c
)acZGDO:[]U?c;?KQ`cGO>G<:[?Zc[E:[c&cE:_?c;??OcDG_?Pc[E?c<E:O<?c[QcU?_G?`c:c<]UW?O[c<QSacQ@c "�Zc�*Q[G<?cQ@c,UG_:<ac,V:<[G=Z��c )acZGDO:[]U?cN?:OZc[E:[c&c:DU??c[Qc:KKQ`c "c[Qc]Z?c:O>c>GZ<KQZ?cNacS:[G?O[�ZcS?UZQO:KcE?:L[EcGO@RUN:[GQOc[Qc<:UYcQ][c[U?:[N?O[�cS:aN?O[c:O>cE?:K[Ec<:U?cQS?U:[GQOZ�c
,:[G?P[cQUcK?D:KKac:][EQUGb?>cGO>G_G>]:KcZGDO:[]V?c #:[?c
.?K:[GQOZEGSc[QcS:[G?O[cG@cZGDO?>c;ac:PaQO?cQ[E?Uc[E:Oc[E?cS:[G?O[c
� &�&� �#1�'#!�/1
;`H«�åã³ÙåW¶¾åN`³´Ëc¬^åÙËåHËåã´Ú¿å·¾´ÞdPS¾�å=SåH¾SåN´¦¦eÍÏSPåÍ´å·¾³ßePf«^åã´ÚåàcÍ`å½ÙH�cÎãåIPåH]´¾QHK�Så TH�Í`åOHÀS�å)SNHÚËSå˳§Så³Wå³ÙÁå¸HÏgS«ÏËå HÞSå HPå½ÙTËÏm³«Ëå¾S^H¾Pc¬^å·HÏfS«ÏåH«Qåh«ËÙÂINSåÀSË·³«ËiKj�kÍãåW³ÂåÌS¾ÞlNSËå¾SPS¾SP�åàSå`HÞSåPSÞU�³·UPåÍ`fËå·Hã§SÎå·³�eNã�å8�SHËSåÀSHPåeÏ�åHÌ�åÙËåH¬ãå½ÙTËÏm³¬Ìåã´Ùå HãåaHÞS�åH«PåËn^«åc«åÍ`SåË·HNSå·¾´ÞcPSP�å (åN´·ãåào��åKTå·¾³ÞnPSPåͳåä³ÙåÙ·³«åÀS½ÚSËÎ�å
�� �&+-)�&���1=Så·I¾×cNj·IÎSåàpÍ`妳ËÎål¬ËÙ¾H«NSå·�H«Ë�åSâN�ÚPn«^å5SPnNH¾SåH«På(Ú¦H«H�å .Wåã³ÚåI¾S嬳Íåq¬ËÙ¾SPåKãåHå¹�H«åàS·H¾ÕhNm·HÍSåàoÎa�å·Hã¦SÐår«åXÙ��åoËåSâ·SNÐSQåHÏåSHNaåßcËqÍ�å/Xåã´ÚåI¾Såc«ËÙ¾SPåKãåHå·�H«åàSå·I¾ÕsNq·HÑSåàcÒaåKÙÏåP³å¬³ÏåaHÞSåI«Ú·Í³QIÍSåc«ËÙ¾H«NTåNH¾P�å·Iã¦S«Íåm«åXÚ¡¡åW³ÂåSHN`åßrËcÏåmËåÁS½Ûp¾SPåÙ«Ïr�åàSåNH«åÞS¾qYäåã´Ù¿åN³ÞSÂI_S�å4«´àn«^åã³Ù¾åt¬ËÜÀH«NTKS«TWeÍËågËåã´ÚÂå¾SË·³ËcKu�cÍã�å8�THËSåN³¬ÏJNÐåã³ÚÂåeËÙÂH«NTåO³¦·H«ãåàvÏ`åH«ãå½ÙSÌÏw³«Ëåã´Úå¦Hãå IÞSå¾S^H¾Pj®^åã³Ù¾åN³ßS¾H^S��� �'�(�0%�&,+1�&�1���-�,"�$�+�1(��åN³�·Hã¦S«ÍËåH¬QåPSPÛNÍoK�SËå¦ÚËÍåKSå·HcPåHÍåÓ`SåÎn¦Så³XåËS¾ÞdNSåH«Påàx��åLSåN³��SNÔSPåHÐN`SN��o«�å;`xÌåH¾¾H«^S¦S«ÐåhËå·H¾Òå³Zåä³Ú¾åN³¬Í¾HNÍåàpÍ`åã´Ú¾åy«ËÚ¾I«OSåN³¦·H«ã�å,Hz�Ú¾S峫å³ÚÂå·I¾ÏåÕ³åN³��SOÎåN³�·Hã¦S¬ÏËåH¬PPSPÙNÍrK�SËåW¾´§å·HÍzS¬ÏËåNH«åMSåN³«Ë{PS¾SPåW¾HÛP�å8�SHËSå S�·åÚËåe«åÙ·b´�Pc«^åÏ`Så�HàåKãå·Hãn«^åã³ÚÀåN³ ·Iã¦S«ÍåHÐåTHN`åÞ}ËcÏ��� �'&��'.�)��1+�* ��+�18�SHËSåKSåHàH¾SåÍ`HÍåË´¦Tå�åH¬På·SÃ`H·ËåH�¢å�å³WåÍ`SåËS¾ÞcNTËåã³Ùå¾SNTkßSå¦IãåKS寴«N³ÞS¾SP崾嫳ÍN³«ËcQSÁTPåÂTHË´HK�Så³¾å«SNTËËHÃãåKãåã³Ú¾ån«ËÚ¾H«NSåNH¾¾nS¾�å>³Ùå¦ÚÌÐå·HãåY³¾åÎ`TËSåËT¾ÞcNSÌår«åWÚ��åHÒåÎaSåÍ|¦Så´WåÞvËhÎ�å<`SÄTåsËåH\³Â¦åNH��SPåH¯å(*6åW´Á¦åÍ`HÎåã³Úåàn£�åKTåIË�SPåͳåËc^åKT\³¾SåËSÂÞoNSËåH¾Så·SÁZ³¾¦SP�å ;`cËåW¶¾¦åËÏHÍSÌåÍaHÏåã³ÚåÙ«PS¾ËÐH°PåÍ`HÍËS¾Þ}NTËå§Iã嫳ÎåKSåN³ÞS¾TPåLãåã³ÙÁåm«ËÙ¾H«NSåNH¾¾gSÀ� � �)''�1'�1 &+-)�&���1(�¤å·HÍoS«ÐËå©ÙËÏåN³¦·�SÐSå³ÚÅå·HÍhSÐåv«W³¾¦HÏ|³«å[³Å¦åKSY´¾SåËSSx¬^åÍ`SåP³Nγ¾�å=Så¦ÙËÑå³KÍH~«åHåN³·ãå Yã³ÙÂåP¾�ÞS¾�Ëå�xNS«ËSåH«PåNÛ¾¾S«ÎåÞH�fPå|«ËÚ¾I«NSåϳ巾´ÞzPSå·Ã³³Yå´Xår«ËÚ¾H¬NS�å 0[åã´ÚåYHq�åͳ巾´ÞuPSåÙËåàoÍ`åÏ`SåN³Â¾SNÏåu«ËÙ¾HNSe«W¶¾¦HÖn³«åm¬åHåÏe¦S�ãå¦H¬«SÆ�åã³Úå¦IãåKSå¾SË·³«ËcK�TåZ³¾åÎaSåKH�I«NSå³YåHåN�Ip¦��� �#�"%+1+-�% ++ '&�1=Såàu��åËÚK¦�Íåã³Ú¾åN�Hj¦ËåH«PåHËË�ËÐåã³Úåe¬åH«ãåàHäåàSå¾TH˳¬HK�ãåNH«åγå S�·å SÐåã³Ú¾åN�Hn¦Ëå·HhP�å>³ÙÀq«ËÚ¾H«OSåN³¦·H«ãå¦Hãå«SSPåã³ÚåγåËÚ·º�ãåNSÂÍHo«ål«Y¶¾¦HÏe´¬åPvÀSNÏ�ã�å .ÏåcËåã³Ú¾åÇSË·³«ÌhKo��ÑãåϳåN³¦·�ãåà�Î`åÎaSc¾å¾S½ÚSËÐ�å8�SHËTKSåHàHÁSåÐaHÐåÍaSåKH�HNSå³Zåã´Ú¿åN¡Ho©åmËåã³Ù¾å¾S˹³¬ËlKr�qÒãåàaSÍ`S¾å³¾å±³Íåã³ÛÅå�«ËÛÀH«NUåO³§·Hãå¹IãËåã³ÙÆåN�Hc¦�å>´ÙÀg«ËÚ¾H¯NSåKSS[xÎå�ËåHåN³ÏÅHNÍåKSÏàSS«åä³ÚåH«Qåã³ÚÁåo«ÌÚÂH«NSåO³¦¹J¬ã'åàSåH¾Så«´Ïå¹H¾ÏãåѳåÒ`HÏåN´«ÏÃHNÍ��� �'.�)���1���&��+�1 1Yåã³ÚÁåm¬ËÙÅH«NTåN`H¬^SË�å·�SHËTå«´Ï�XãåÚËåLSZ´¾Såã´ÚÃå¬SâÏåÞhËmÏå˳åàSåNIå§H�SåÍ`TåH··Ç´·¾tHÐSåNaH«^SË×´åbS�·åã³ÙåÅSNS�ÞSåã³Ú¾å¦Hâr¦Ú¦åKS°SYhÎË�å2[åã´ÙÂåh«ËÚÂI«NSåN³¦»H«ãåP³SË嫳ÐåºHãåã´ÙÃåN�Hc¦åh«å!"åPHãË�åÓ`SåKI�HNSåàm��HÙϳ¦HÎ~NI��ãåLSåK���SPåÏ´åã³Ù��� �'&(�0%�&,�1 .Yåä³ÚÅåINN´Ú«ÍåcËå ÞSÈå#�åPHãËå·HËÏåQÙS�åã³Úåàj��åÁSOSnßSåHå�SÏÍS¾åËÍHÏq¬^åÍaHÏåã´Üå`HÞSå��åPHãËåϳå·Hãåã´Ú¾HNN´Ú¬Ïåi¬åYÚ���å8H¾ÍzH�å·Hã¦S«ÍÌåàc�¥å«´ÏåKSåHNNS·ÍSPåÙ«�SËËå³Ï`SÂácÌSå¬S^´ÑsJÍSQ�å8�SHËSåKSåHáH¾SåÏ`HÏå�XåJåKH�I«NSå¾S¦Hn«Ë
�å Ú¬·HpP�åàSå¦HãåÆSYVÅåã³Ü¾åHNN´Ü«ÐåϳåHåN³��SNÏy³«åH^TNãåH«Påã³ÚåH¬Påã´ÚÃån¦¦SPpHÎSåXH¦f�ãå¦S§KT¾Ëå¦HãåKTåPcËN`HÁ_SPåW¾³¦åÐa{Ëå·ÂHOÏcNS�å .YåÏ`gËåyËåسå NNÙÂ�åã´Úåàr��åLTå´Ï�XsSPåKãåÀS^Ú�I¾åH«PåNS¾ÏkYhSPå¦Hm�åÏ`IÍåã³Úå HÞSå �åPIãËåϳåYh«PåI�ÍS¾«HÐeÞSå¦SPoNH�åOI¾S�å+Ú¾i¬^åÏ`HÑå � PHãå·SÂ�³P�å³Ü¾å·`ãËhNmH«åào��å³®�ãåKTåHK�SåϳåÐÁSIÍåã³Úå³åI«åS©SÂ^S°NãåKIËzË�å�� � ++��1�((' &,%�&,+1=Så¾S½ÚSËÐåÍaHÏåã³Ýå_lÞSå�!åa³ÙÅË嬴ÍoNSåpYåÚ«HL�Tåδå�SS·åã³ÚÉåH··³v«Ð¦S«Ð�å .YåÍapËåcË嫳Ðå·³ËËfM�S·�SIÌSå^jÞSåÐ`Så¦Hâ�¨Ú©å®³ÐrNSå·´ËËnL�S�å;ahËåà���åH��³áåÙÌåÖ³å�SS¹å ÚÆåËNaSQÜ�Så³¹SåZ³ÂåºHÏcS«ÏËåϳåKSåËSS«årWå·³ËÌgK�S�å9�SIÌS`S�¹åÙËåϳåËSÇÞSåã³ÚåLSÏÏSÁåKãå�SS»c«^åã³ÙÂå¾S^Ù�HÅ�ãåËNaSPÚ�SQåH··´m«Ï¦S«Ï�å-Hc�ÚÂSåÏ´åËa´àåX¶Ååã³ÛÀåH··³e¬Ï¦T«Íåàd£�å¾SËÛ�ÍåfåH�"�嬳�Ëa³àåXSSå³ åã³Ù¾åJNO³Û¬×åÏ`HÍå¦ÙËÍåKSå·HxPåKSZ¶ÆSåä³ÙåNH«åKSåËSS«åH^Hr¬�
7ÙÀå¼ÇINÏcNTå�ËåNµ¦¦c×ÎSRåÍ´å·Å³ÞmPd«^åÍ`TåKSËÍåÍÅSIΦS«Ôåͳå³Ú¾å¹HØ�T¬ÕË�å7ÙÅå·ÅcNSËåHÆSåÈS»ÇSËS«ÎHÐsÞSå³[åÍ`SåÙËÙH�åH«PåNÚËγ¦H¾ãåN`H¾^SËåZ³Êå³ÙÈåIÂSH�å ;aH¬�åã´ÙåY³ÅåÙ«PSÈËÏI®Pc«^å³ÚÅå·Hã¦T¬Õå·³��Oã�å8�SHËTå�SÍåÜËå�«´àåvYåã³ÚåaHÞSåH«ãå½ÜSËÐr´Ëå³ÊåN³«NS¾«Ì�å
3åÙ«QSÅËÔH²PåH«PåH^¾SSå׳å×aSåÍSÁªËå³YåÍbfËå¹Jã©SÍ廳 �Nã$å
:c^«IÏÚ¾S%å?@ABCBC?DBDCDE?DDåFå +HÏS&åDBDDDE???BCCåGå
What is your primary problem bringing you here today? (please describe your symptoms) __________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
How long have you had these issues? ___________________________________________________________________________________
Do you use tobacco products? ☐ Never ☐ Quit (quit date:________________) ☐ Yes (if yes, please describe the type, how much, and how often) __________________________________________________________________________________________________________________
How often do you drink alcohol? ☐ Never ☐ Daily ☐ Weekly ☐ Occasionally
Personal use of recreational drugs? ☐ No ☐ Yes
Do you have any allergies? ☐ No ☐ Yes (if yes, please list any allergies to medications, IV contrast or pollens) __________________________________________________________________________________________________________________
Have you ever had a CT scan? If so, when and where? ____________________________________________________________________
__________________________________________________________________________________________________________________
Please list any medical problems: ______________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Please list previous surgeries/procedures:
Procedure/Surgery Date Procedure/Surgery Date
1.______________________________________________________ 2._________________________________________________________
3.______________________________________________________ 4._________________________________________________________
5.______________________________________________________ 6._________________________________________________________
List medications you are currently taking: (including prescriptions, over the counter, and herbal)
Medication Dose Frequency Medication Dose Frequency
1.______________________________________________________ 2._________________________________________________________
3.______________________________________________________ 4._________________________________________________________
5.______________________________________________________ 6._________________________________________________________
7.______________________________________________________ 8._________________________________________________________
9.______________________________________________________ 10.________________________________________________________
Do you have problems with any of the following? Please circle yes or no.
General: Weight loss……………..……….. yes no Weight gain………….………….. yes no Fatigue.……………….…………. yes no Night sweats…………………..… yes no Fevers/chills………………….…. yes no Easy bleeding/bruising…….…… yes no Heat/cold intolerance……..……. yes no Heavy menses……………..…… yes no Excessive sweating………..…… yes no
Face: Pain……………………..……….. yes no Numbness………………..……… yes no Twitching…………………..…….. yes no Weakness…………………….…. yes no Lop-sided…………………….….. yes no Previous Bell’s palsy…………… yes no
Eyes: Recent changes in vision…….… yes no Blurry/double vision…………..… yes no Wear glasses/contacts…….…… yes no Floaters…………………….……. yes no Glaucoma………………….……. yes no Cataracts…………………….….. yes no Watery or itchy eyes………….… yes no Dry eyes…………………….…… yes no Previous eye surgery……….….. yes no Blindness…………………….….. yes no
Ears: Ear pain……………………..…… yes no Ear drainage………………..…… yes no Ear pressure………………..…… yes no Ear fullness………………..…….. yes no Ringing/roaring noises…….…… yes no Pulsing noises……………..……. yes no Dizzy…………………………..…. yes no Vertigo………………………..….. yes no Previous ear surgery………..….. yes no Ear infections………………….… yes no Use Q-tips…………………..…… yes no Too much wax…………………… yes no Ear tubes………………….…….. yes no
Hearing: Hearing Loss………………… yes no Recent changes in hearing… yes no Hearing going up and down.. yes no Use of hearing aids…………. yes no Deafness…………………….. yes no
Nose: Obstruction…………………….… yes no Post-nasal drainage………….… yes no Nasal congestion/stuffiness…… yes no Purulent/foul nasal drainage..… yes no Itchy, watery nose…………….… yes no Frequent sneezing……………… yes no Nasal allergies………………..… yes no Nosebleeds……………………… yes no Difficulty breathing through nose…………….……… yes no Nose surgery………….………… yes no
Sinuses: Sinus headaches………………………..….. yes no Sinus pressure: cheeks…………………….. yes no Sinus pressure: forehead…………………… yes no Sinus pressure: eyes……………..………… yes no Colds last longer than average..…………… yes no Frequent sinus infections…………………… yes no Chronic sinus infections………………….…. yes no Sinus surgery………………………………… yes no Tooth pain……………………………….……. yes no Altered smell/taste…………………….…….. yes no
Throat: Sore throat………………………..……….… yes no Dry mouth/throat……………………….……. yes no Difficulty swallowing………………………… yes no Painful swallowing…………………….…….. yes no Frequent throat/tonsil infections…………… yes no Something stuck in throat……………..…… yes no Hoarseness………………………………….. yes no Voice wears out quickly…………………….. yes no Weak voice………………………….……….. yes no Voice tremor or stutter………………….…… yes no Frequent throat clearing……………………. yes no Increased phlegm.……………………..…… yes no Food sticking or going down wrong……….. yes no Lesion in mouth/throat………………….…… yes no Previous tonsil/adenoid surgery………..….. yes no
Neck: Pain………………………………..………….. yes no Mass/lump…………..………………….……. yes no Goiter…………………………………….…… yes no Previous spine surgery……………….…….. yes no Decreased neck mobility……….….…….…. yes no Thyroid problem……………………….…….. yes no Thyroid nodule..……………………………… yes no
Skin: Skin cancer…………………………….…….. yes no Skin lesion…………………….……………… yes no Dry skin………………………………………. yes no Rashes……………………………………….. yes no Changes to skin/hair/nails……………….…. yes no Eczema…………………………………..…… yes no
Immunologic: Abnormal/large lymph nodes……..….……. yes no Rheumatoid arthritis……….………..……… yes no Lupus…………………….…….……..……… yes no Sjogren’s……………………..………..…….. yes no Wegener’s.…………………..………..…….. yes no Sarcoidosis…………………………….…….. yes no Psoriasis………………………..…………….. yes no Previous transplant.…………………..…….. yes no HIV/AIDS……………………………..….….. yes no Hepatitis B/C……………………….………… yes no
Gastrointestinal: Stomach pain/cramping…………….…….… yes no Diarrhea………………………….…………… yes no Constipation…………………………………. yes no Nausea………………………….……………. yes no Vomiting……………………………….……… yes no Appetite changes………………….………… yes no Blood in stool………………………………… yes no Heartburn…………….…………………….… yes no
Neurologic: Stroke……………………………………….… yes no Headaches…………………….………….….. yes no Migraines……………………….…………….. yes no Numbness/tingling……………….………….. yes no Weakness…………………………….………. yes no Walking problems………………………….… yes no Frequent falls………………………………… yes no Difficulty thinking/memory loss…………….. yes no Passing out……………………….………….. yes no Dizzy or giddy feeling……………………….. yes no Light-headed..…………………………..…… yes no
Heart: Heart attack………………………………….. yes no Heart failure………………………………..… yes no Chest pain………………………………….… yes no Abnormal rhythm…………………………….. yes no Palpitations/funny heart beat………………. yes no Blood thinner use……………………………. yes no Pacemaker…………………………………… yes no Previous heart surgery/CABG………..…… yes no Shortness of breath lying flat……….…..…. yes no Pain in calves when walking……………….. yes no Fast or slow heart rate……………..………. yes no High blood pressure…………………..……. yes no Swelling in legs……………………………….yes no
Lungs: Breathing problems…………………………. yes no Asthma………………………………..…..…. yes no COPD/emphysema………………………..… yes no Smoking………………………………….…… yes no Dry cough……………………………………. yes no Cough with phlegm/sputum………………… yes no Cough up blood……………………………… yes no Wheezing…………………………………..… yes no Shortness of breath at rest……………….… yes no Shortness of breath walking………..……… yes no Noisy breathing……………………………… yes no Use of oxygen.………………………………. yes no
Sleep: Difficulty falling/staying asleep…….………. yes no Problems sleeping…….……………….……. yes no Sleep apnea…………………………….…… yes no Use of CPAP/BiPap……………………….… yes no Snoring…………………………………….…. yes no Wake up frequently……………………….…. yes no Stop breathing at night…………….……….. yes no Choking/gagging during sleep…..………… yes no Sleepy during day/not well rested….……… yes no
Other: Osteoarthritis………………………………… yes no Diabetes……………………………………… yes no Depression………………………….…….….. yes no Anxiety………………………………….…….. yes no Bipolar disorder………………………..…….. yes no Fibromyalgia………..………………….…….. yes no ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________