Patient medical history

SINU-CLEAR, INC. , Office of Harvey D. Paley, M.D._________ Welcome to our office! Please take the time to fil out this form as thoroughly as possible. PATIENT NAME: __________________________________DATE:_________________ Referred By:___________________________________________________________________ Primary Complaint:______________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How long have you had these symptoms?_____________________________________________ Basic Medical History (Please check those that apply): □ Hepatitis/ jaundice/ kidney problems □ Epilepsy/ seizures/ fainting/ black- outs □ Shortness of breath □ Respiratory problems/ asthma/ bronchitis □ Stroke □ Thyroid disorder □ Hay fever/ allergies □ Heart disease/ heart murmur/ angina/ irregular heartbeat □ Tuberculosis □ Emphysema □ Reflux □ Blurred or double vision □ Migraines Are you allergic to any medications? □ NO □ YES If yes, please list which medications you are
allergic to:______________________________________________________________________
Have you ever been tested for other allergies? ? □ No □ Yes
Have you ever had allergy shots? □ No □ Yes Was it helpful? □ No □ Yes
Are you currently using or have you ever used □ Afrin/Neosynephine □ Sudafed □ Benadryl
□Cortisone or oral steroids such as Medrol □ Nasal saline irrigations/ Grossan irrigator
□Claritin or Allegra
Please list any other medications and dosages including vitamins, herbs, or over the counter
medications that you are currently taking or recently discontinued. Please include aspirin and
ibuprofen: _____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you use recreational drugs? □ No □ Yes If yes, please list:____________________________
Do you use tobacco? If yes, how much? ______________________________________________
Do you use alcohol? If yes, rarely, socially, frequently, or daily? __________________________
Do you drink caffeine? If yes, how much including coffee, tea, and soda? ___________________
Name_________________________________________________ Ear, Nose, and Throat History
Have you had your tonsils removed? □ No □ Yes ~ Date: __________________________________ Have you had your adenoids removed? □ No □ Yes ~ Date: ________________________________ Prior surgery for snoring or sleep apnea? □ No □ Yes ~ Date: ______________________________ Prior nasal surgery? □ No □ Yes ~ Date: _______________________________________________ Did your symptoms improve? □ No □ Yes ~ Drastic improvement / Little improvement/ No change Have you ever been hospitalized for any other surgical procedure or serious illness? □ No □ Yes If yes, please give details dates:_____________________________________________________________ ______________________________________________________________________________________  Difficulty breathing through nose/Congestion  Cough If yes, is it productive? □ Yes, I’m coughing up phlegm. □ No, it is a dry cough.  Recurrent sinus infections. If yes, please indicate number of infections in the past year: ______  If applicable, please list all antibiotics you have taken in the past year: ___________________ ____________________________________________________________________________Date last course of antibiotics was taken:___________________________________________ Did your symptoms improve after finishing the antibiotics? □ Yes □ No Do you have difficulty falling asleep? □ Yes □ No
Have you ever been told by a partner that you have difficulty breathing in your sleep? □ Yes □ No
Have you ever fallen asleep while driving? □ Yes □ No While at school or work? □ Yes □ No
Have you ever had a CT Scan of your sinuses done? □ Yes □ No If yes, give date:______________
If you are coming in for a consult for the Sinu-Clear procedure, please bring the films with you.

Source: http://www.sinu-clear.com/pdf/PATIENT%20MEDICAL%20HISTORY.pdf