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HEALTH UPDATE FORM
Please complete prior to your appointment.
Health Update Form
First Name
*
Last Name
*
Phone
Email
*
Date
*
MM slash DD slash YYYY
Referring Doctor
*
Primary Care Doctor
*
Reason for your appointment
*
What medications have you taken for this problem?
*
Persons to whom results/information can be released:
*
Current Medications (All medications taken including over the counter and vitamins)
*
Medication
Dosage/How Often
Drug Allergies and Reactions
*
Medical History (check all that apply)
Heart Attack
Heart Disease
Irregular Rhythm (A-fib)
Vascular Disease
High Blood Pressure
Stroke
Emphysema/COPD
Asthma
Acid Reflux
Stomach Ulcer
Hiatal Hernia
Diabetes
Tuberculosis
Thyroid Disease
Kidney Disease
HIV (AIDS)
Anemia
Hemophillia
Bleeding Problems
Blood Clot
Transfusion
Arthritis
Hepatitis
Cancer
Other medical problems
*
Surgical History (check all that apply)
Tonsillectomy
Ear Tubes
Nasal Surgery
Sinus Surgery
Other Ear
Cancer
Carotid Surgery
Thyroid/Parathyroid
Heart/Lung
Abdominal
Brain
Orthopedic/Back/Neck
Hernia
Cholecystectomy
Date of your Tonsillectomy
*
MM slash DD slash YYYY
Date of your Ear Tubes
*
MM slash DD slash YYYY
Date of your Nasal Surgery
*
MM slash DD slash YYYY
Date of your Sinus Surgery
*
MM slash DD slash YYYY
Date of your Other Ear Surgery
*
MM slash DD slash YYYY
Date of your Cancer
*
MM slash DD slash YYYY
Date of your Carotid Surgery
*
MM slash DD slash YYYY
Date of your Thyroid/Parathyroid Surgery
*
MM slash DD slash YYYY
Date of your Heart/Lung Surgery
*
MM slash DD slash YYYY
Date of your Abdominal Surgery
*
MM slash DD slash YYYY
Date of your Brain Surgery
*
MM slash DD slash YYYY
Date of your Orthopedic/Back/Neck Surgery
*
MM slash DD slash YYYY
Date of your Hernia Surgery
*
MM slash DD slash YYYY
Date of your Cholecystectomy Surgery
*
MM slash DD slash YYYY
Other Surgeries
*
Family History (check all that apply)
Hearing Loss
Allergies
Seizures
Heart Disease
Kidney Disease
Diabetes
Thyroid Disease
Strokes
Bleeding Problems
Anesthesia Problems
If you checked any of the above, please list their relation to you.
Hearing Loss
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Allergies
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Seizures
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Heart Disease
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Kidney Disease
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Kidney Disease
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Diabetes Disease
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Thyroid Disease
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Strokes
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Bleeding Problems
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Anesthesia Problems
*
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Paternal Grandmother
Mother
Father
Sister
Brother
Occupation
*
Marital Status
*
Pharmacy Name
*
Pharmacy Phone Number
Do you smoke?
*
Yes
No
If you selected Yes to smoking, please list cigarettes per day
Have you ever smoked?
*
Yes
No
Year you quit smoking
Any other forms of tobacco?
Do you drink any alcohol?
*
Yes
No
Drinks per week
Do you use recreational drugs?
ROS: Do you have or have you had any of the following? (check all that apply)
Heat/Cold tolerance
Fatigue
Fever
Loss of appetite
Night sweats
Weight loss
Seasonal allergies
Facial pressure
Headache
Dizziness
Ear drainage
Ear Pain
Ear fullness
Hearing Loss
Ear ringing
Change in vision
Double vision
Cough
Coughing up blood
Nosebleeds
Loss of smell
Nasal congestion
Postnasal drip
Running nose
Snoring
Dry mouth
Mouth sores
Problems swallowing
Painful swallowing
Throat pain
Voice changes
Enlarged lymph nodes
Chest pain
Shortness of breath
Nausea
Vomiting
Heartburn or reflux
Easy bleeding
Muscle pain
Joint pain
Rash
Numbness/tingling
Seizures
Migraine
Depression
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