Health & History Form
Maryland, Ear, Nose and Throat, LLC
PATIENT INFORMATION SHEET Date of Service: ________________
REASON FOR VISIT: ___________________________________________________________
REFERRING DOCTOR: Name: ______________________________________ Telephone ________________________________________
Fax: _________________________________ Address ______________________________________________________________________________
PREFERRED PHARMACY PHONE #: _____________________________________________
PLEASE PLACE AN X IN THE BOX [ ] IF YOU HAVE ANY OF THE FOLLOWING:
Constitutional symptoms: fever [ ], weight loss [ ], general allergies (such as hay fever or seasonal allergies) [ ]
Cardiovascular: chest pain [ ], angina or heart attack [ ], heart palpitations [ ], high blood pressure [ ].
Respiratory: wheezing [ ], emphysema [ ], spitting blood [ ], cough [ ], shortness of breath [ ], production of sputum [ ].
Gastrointestinal: difficulty swallowing [ ], nausea/vomiting [ ], jaundice [ ], loss of appetite [ ], changes in bowel habits [ ], constipation [ ], diarrhea [ ], blood in the stool [ ].
Genitourinary: frequent urination [ ], difficulty in urination [ ],
Blood in the urine [ ] recurrent urinary infections [ ].
Musculo-skeletal: muscle weakness [ ], back pain [ ] arthritis [ ]
Integumentory: skin rash [ ] or wheals [ ].
Neurologic/ psychiatric: chronic headaches [ ], weakness of the extremity [ ], seizure disorder or epilepsy [ ], numbness [ ] depression [ ], mental illness [ ].
Endocrine: diabetes [ ], thyroid disorders [ ].
Hematologic/lymphatic: cancer [ ] bleeding tendency [ ], anemia [ ].
ALLERGIES: (List all current medication, iodine, shellfish, environmental or other allergies)
MEDICATIONS YOU ARE TAKING: (List all current prescriptions/non-prescription medications)
FAMILY HISTORY: (Has anyone of your immediate family suffered from the following diseases, if yes please specify who is the member):
Hearing loss [ ], angina or heart attack [ ], asthma [ ] diabetes [ ], epilepsy or seizure disorder [ ], bleeding disorder [ ], cancer [ ], anesthesia problems [ ].
HOSPITALIZATION AND SURGERIES Reason and Dates: ________________________________________________________________________________________________________________________________________________________________
SOCIAL HISTORY: Occupation:
Do you smoke? Yes [ ] No [ ] If yes how much? ___________How long? ______________
Alcohol intake [ ] (if yes how much) Drugs [ ] (if yes, what type)
HIPAA NOTICE OF PRIVACY PRACTICES
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website, MarylandENT.com, or asking for one at the time of your next appointment.