Patient History Question Brevard Ear, Nose, and Throat Center

Brevard Ear, Nose and Throat Center

Patient History Question:
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PATIENT INFO
Name (required)		Email (required)
Who referred you? (required)		Reason (required)

Symptoms: (required)
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For how long? (required)
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What treatment have you received? (required)
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Are you currently or do you regularly experience: (Please check all that apply)
Constitutional	Weight loss	Fatigue	Fever

Eyes	Blurred Vision	Double vision	Eye pain

Ears, Nose, Throat & Mouth	Headaches Ringing in ears Pressure sensation in ear Ear pain Nasal obstruction Nose bleeding Purulent nasal discharge Sore throat Change in voice Neck tenderness	Vertigo/Dizziness Roaring sound in ears Itching in ear Nasal pain Sinus pain Nasal discharge Mouth pain Snoring Frequent throat clearing Dentures	Hearing loss Ear fullness Ear discharge Decreased sense of smell Nasal congestion Postnasal drip Swollen glands Hoarseness Difficulty swallowing Lump in throat sensation

Cardiovascular	Chest pain	Hypertension	Palpations

Respiratory (Lungs)	Shortness of breath Coughing blood	Wheezing	Cough

Gastrointestinal (Stomach)	Nausea Painful swallowing	Vomiting Excessive belching	Difficulty swallowing Heartburn/Acid reflux

Genitourinary	Urgency	Frequency	Pain when urinating

Integumentary (Skin)	New skin lesions	Pigmentation changes	Changes to existing skin lesions

Neurological (Nerves)	Tremors Tingling or numbness	Seizures	Loss of balance

Musculoskeletal	Joint pain	Joint swelling	Muscle pain

Endocrine	Cold intolerance Weight loss	Heat intolerance Weight gain	Loss of hair Hot flashes

Psychiatric	Anxiety	Depression	Difficulty sleeping

Hematologic/ Lymph Nodes	Easy bleeding	Easy bruising	Lymph node enlargement or tenderness

Allergic/ Immunologic	Reaction to anesthesia	Sneezing	Itchy watery burning eyes

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