OSNT: Otolaryngology Specialists of North Texas
Patient Intake Form – Adult
Download PDF Adult Patient Intake Form 3-24-14
PATIENT INFORMATION
Last Name ________________________ First Name ____________________ M.I. ______ Date of Birth ____/____/______
Age _____ Sex _____ SSN :_____________________Race __________________ Ethnicity ____Hispanic _____Not Hispanic
Address ________________________________ Apt # ______ City ____________________ State _________ Zip ________
Email Address _____________________________________________ Preferred Language __________________________
Home Phone ______________________ Cell Phone ______________________ Work Phone _________________________
How may our office best contact you? (check one) _____Home Phone _____Cell Phone _____Work Phone
Preferred method of appointment reminder? _____Text _____Email _____Phone (circle: cell or home)
Occupation ________________________________________ Employer _________________________________________
PHARMACY
Pharmacy Name _______________________________________ Phone _______________________ Fax __________________
Address __________________________________________________ City/State/Zip ___________________________________
INSURANCE INFORMATION
Primary Insurance Carrier _____________________________ Secondary Insurance Carrier ___________________________
ID# ______ _________________________________________ ID# _______________________________________________
Group # ____________________________________________ Group # ___________________________________________
Subscriber Name ____________________________________ Subscriber Name ____________________________________
Subscriber SS # ______________________________________ Subscriber SS# ______________________________________
Subscriber Birth Date _________________________________ Subscriber Birth Date ________________________________
Relationship to Patient ________________________________ Relationship to Patient _______________________________
Employer ___________________________________________ Employer __________________________________________
REFERRING PHYSICIAN
Physician Name _______________________________ Practice Phone _____________________________________
May we thank someone else (non-physician) for referring you to our office? __________________________________________
ALLERGY INFORMATION
Drug Allergies _____________________________________Environmental Allergies______________________________________
Are you allergic to latex? _____ Yes _____ No Are you allergic to medical tape? _____ Yes _____ No
SOCIAL HISTORY
Exercise: Yes _____No_____ How often: Daily______2-3x a week________3-4x a week________
Use Alcohol: Never______1 a month______2-4 a month______2-3 a week______4+ a week ____Number in one occasion______
How often did you have 6+ drinks on one occasion in the past year _______Never______ Monthly_______ Weekly_______ Daily
Do you CURRENTLY smoke or use tobacco products: Yes___ No ___What do you use________ How often ____Daily ____Occ.
Have you EVER smoked or used tobacco products: Yes_____ No_____ How often did you use: Everyday____ Occasionally_____
How much ____________ How many years _________When did you quit __________What did you use ____________________
Have you used drugs in the last 12 months (Marijuana/Heroin/LSD/Cocaine/Other) Yes________ No________
Patient Name: __________________________________________________________ Date of Birth: ___________________
MEDICATION
Please list all medications you are currently taking including over the counter medications, herbals, etc.
____ No Current Medications
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________N
HEALTH HISTORY
What problems are you here for today? __________________________________________________________________________
Do you currently have or frequently experience:
____Alcoholism ____Cancer ____Heart Failure ____Mental Illness
____Anemia ____Depression ____Hepatitis ____Reflux
____Arthritis ____Diabetes ____High Blood Pressure ____Sleep Apnea
____Atrial Fibrillation ____Emphysema ____High Cholester0l ____ Stroke
____Asthma ____Epilepsy/Seizures ____HIV/AIDS ____ Thyroid Problem
____Birth Defects ____Glaucoma ____Kidney Disease ____ Tuberculosis
____Bladder Disease ____Headaches ____Liver Problem ____Weight Loss/Gain
____Bleeding Disorder ____Heart Attack ____Lung Problem ____Other:__________________
Have you undergone any of the following surgeries?
Tonsillectomy Date:____________________ Adenoidectomy Date:______________________
Ear Surgery Date:____________________ Thyroid Surgery Date:______________________
Ear Tubes Date:____________________ Nasal/Sinus Surgery Date:______________________
Other______________________________________________________________________________________________________
FAMILY HISTORY
Has anyone in your family had:
____Alcoholism ____Cancer ____Heart Failure ____Mental Illness
____Anemia ____Depression ____Hepatitis ____Reflux
____Arthritis ____Diabetes ____High Blood Pressure ____Sleep Apnea
____Atrial Fibrillation ____Emphysema ____High Cholester0l ____ Stroke
____Asthma ____Epilepsy/Seizures ____HIV/AIDS ____ Thyroid Problem
____Birth Defects ____Glaucoma ____Kidney Disease ____ Tuberculosis
____Bladder Disease ____Headaches ____Liver Problem ____Weight Loss/Gain
____Bleeding Disorder ____Heart Attack ____Lung Problem ____Other:__________________
Other:_____________________________________________________________________________________________________
Patient Name:___________________________________________________________Date of Birth: ____________________
PATIENT REVIEW OF SYSTEMS
Do you consider yourself generally: __________Healthy _________Change in appetite ______________ Fever _____________
Do you frequently have or frequently experience: (Please check ALL that apply)
Allergy/Immunologic ____None ____Reactions ____Sneezing ____Eye Irritation
____Other:_________________________
Eyes ____None ____Irritation from light ____ Blurred Vision ____Other_______________
Ears, Nose, Throat ____None ____Itching Nose ____Rhinitis ____ Bruxism (teeth grind)
& Mouth ____Nose Blocked ____Sores in Mouth ____Post Nasal Drip
____Teeth Hurt ____Painful Swallowing ____Pressure in Ear
____Hearing Loss ____Difficulty Swallowing
Respiratory (Lungs) ____None ____Cough ____Shortness of Breath while sitting
____Wheezing ____Other:__________________________________
Cardiovascular (Heart) ____None ____Cyanosis ____Palpitations/Fluttering of Heart
____ Pain in Chest ____Shortness of Breath while exercising
Gastrointestinal ____None ____Pain ____Constipation ____Diarrhea
____Indigestion ____Other:____________________________________
Hematologic/Lymph Nodes ____None ____Bleeding Easily ____Night sweats ____Other:______________
Genitourinary ____None ____Hesitation when urinating ____Urination at Night
____Pain when urinating ____Other:______________
Musculoskeletal ____None ____Cramping ____Soreness ____Weakness
____Other:________________________________________________________
Integumentary ____None ____Dry Skin ____Itchy Skin ____Lesions on Skin
____Bleeding ____Other:________________________
Neurological (Nerves) ____None ____ Dizziness/Vertigo ____Ringing in Ears ____Abnormal Movements
____Twitch ____Other:___________________________________
Psychiatric ____None ____Situational Stress ____Depression ____Mood Swings
____Anxiety ____Other:__________________________________
Endocrine ____None ____Hot Flashes ____Hair Loss/Growth ____Heat
____Cold ____Other:____________________________________
Patient Comments:
Signature of Patient/Guardian__________________________Date_______________________