Medical History
Downtown ENT
Full name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone number
*
-
Area Code
Phone Number
Email
example@example.com
Reason for consultation:
*
Allergies/hayfever
Cough
Deviated septum
Earache
Ear discharge
Ear infection
Ear wax
Foreign body ear
Foreign body nose
Foreign body throat
Headache
Hearing loss
Hoarseness
Laryngitis
Mouth/tongue/gum/lip problem
Nasal obstruction
Neck mass
Nosebleed
Nose fracture
Post-nasal drip
Ringing/other noise in ears
Sinus problems
Sinus surgery
Sleep apnea
Sore throat
Snoring
Swallowing problem
Tonsil problem
Vertigo
Vocal cord nodes/nodules/polyps
Other
Medical problems/Medical history
*
Past surgeries
*
Medication list (include vitamins, supplements, over the counter)
*
List any medication allergy & reaction
*
Do you use tobacco?
*
Yes, daily
Yes, occasionally
Never
Quit
List any recreational drugs
Alcohol use
*
None
Less than 1 a day on average
1-2 per day
3 or more per day
Please upload the FRONT of your insurance card
*
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Please upload the BACK of your insurance card
*
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of
Please upload your photo ID
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Home address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy (name and phone)
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