EAR, NOSE, THROAT AND ALLERGY CENTER

EDITH A. MCFADDEN, MD, MA, FAAOA - DIRECTOR

Diplomate, American Board of Otolaryngology
Fellow, American Academy Otolaryngology/Head and Neck Surgery
American Academy Otolaryngic Allergy Member
American Rhinologic Society

PATIENT INFORMATION SHEET

PATIENT NAME (first)__________(middle)_______(last)________________ DATE OF BIRTH___/___/____
PATIENT AGE ___________PATIENT SOCIAL SECURITY NUMBER ________-_____-_______
ADDRESS _____________________________________________________________
CITY ______________________________________STATE ________ ZIP CODE ___________
TELEPHONE (home) (______)______-_________ (work) (_______)_______-_______________
PARENTS' NAMES: MOTHER (first)_______________________(maiden)___________________________________
FATHER (first)__________________________(last)___________________________________________________
LEGAL GUARDIAN (first)__________________________(last)___________________________________________
PHYSICIAN WHO RECOMMENDED THIS CONSULTATION ________________________________________________
ADDRESS________________________CITY_____________STATE___ZIP CODE _________
TELEPHONE (______)______-___________
FAMILY PHYSICIAN ________________________________________________________
ADDRESS___________________________CITY_____________STATE___ZIP CODE _____________
TELEPHONE (______)______-______________
INSURANCE NAME_______________________________GROUP NUMBER______________________________
POLICY NUMBER_______________________________TELEPHONE (______)______-_____________
EMPLOYER'S NAME____________________________________________________________________

NO SMOKING POLICY: I understand that no smoking is permitted in this office.
MEDICAL CONSENT: I, the undersigned, hereby consent to medical care and treatment as deemed necessary and proper by the medical staff of the EAR, NOSE, THROAT AND ALLERGY CENTER for the patient identified above.
FINANCIAL AGREEMENT AND ASSIGNMENT: I, the undersigned, agree, whether signing as agent or as patient, that I am financially
responsible for all charges incurred. Assignment of commercial insurance benefits to EAR, NOSE , THROAT AND ALLERGY
CENTER does not reduce the responsibility for payment. Should this account be referred to any attorney for collection, the undersigned shall also be responsible for reasonable attorneys' fees and any additional fees associated with the collection process. Further, by signing below, I authorize payment to be made directly to EAR, NOSE , THROAT AND ALLERGY CENTER and/or
EDITH A. MCFADDEN, M.D. for the benefits otherwise payable to me by any third party including any major medical benefits. I also agree to be billed directly and to pay for any administrative fees incurred from missed appointments or those I do not cancel or reschedule at least 24 hours in advance.
MEDICAL CLAIMS: I request that payment of authorized Medicare benefits, if applicable, be made either to me or on my behalf to EAR, NOSE , THROAT AND ALLERGY CENTER for any services furnished me by that provider.

PATIENT OR GUARDIAN SIGNATURE:_________________________________________________________ Today's Date: ___/___/___

PATIENT SIGNATURE:_________________________________________________________Date of Birth ___/___/___ Age_______y.o. Today's Date: ___/___/___

THE FOLLOWING ARE A NUMBER OF QUESTIONS DESIGNED TO HELP DR. MCFADDEN UNDERSTAND
YOUR PRESENT PROBLEMS AND ANY PREVIOUS HEALTH PROBLEMS YOU HAVE HAD, AS WELL AS
YOUR LIFESTYLE. THIS WILL HELP MAXIMIZE THE CARE YOU RECEIVE.

PLEASE FILL OUT ALL OF THIS QUESTIONAIRE. THANK YOU.

A. WHY ARE YOU (OR YOUR CHILD) HERE TODAY TO SEE DR. MCFADDEN?
List each complaint and when it started. and what, if anything, makes it better or worse. 1._________________________________________________________________________________
2._______________________________________________________________ __ 3._______________________________________________________________________

B. General Allergy Symptoms: (List the three worst symptoms) 1.)_______________________2.)_____________________3.)________________________
__Worse or better outdoors __Worse or better indoors __Worse 30 minutes after lying down __Worse after lights are on 1 hr.
__Worse on windy days __Worse in warm or cool air __Worse when sweeping __Worse in certain rooms
__Worse on clear days __Worse with temperature change __Worse when dusting __Worse near a barn
__Worse outdoors in AM __Worse in cold weather __Worse in low, damp area __Worse around animals
__Worse outdoors in PM __Worse on cool evenings __Worse mowing or playing in grass Which ones _____________________________________
Are your symptoms constant or intermittent (off and on)? _______________________________________________________
During which seasons do you have symptoms?_______________________________________ During which months are symptoms most severe?_______________________________________

C. Medical History (check the following medical conditions you are experiencing or have experienced in the past):
__High blood pressure __Hayfever __Sinus disease __Croup __Stomach/Intestine disease __Tuberculosis
__Heart disease __Drug allergy __Sinus headaches __Skin disease __Liver disease __Depression
__Bronchitis __Milk allergy __Migraine headaches __Ulcers __Kidney disease __Seizures
__Asthma __Hives __Broken nose __Gastric reflux __Thyroid disease __Eating problems
__Diabetes __Nasal Polyps __Deviated nasal septum __Colitis __Arthritis __Other______________________________
List All Surgeries and Hospitalizations:_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
Please List All Medicines You Take Now __________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________
Are you using contraception methods? (If so, which type?__________________________________________________ Last menstrual period _________________________
Which medicines relieve your allergy symptoms? ___________________________________________________________________________________________________
Please list all over-the-counter vitamins, etc. you take regularly: ________________________________________________________________________________________
Please list any medicines you are allergic to: _____________________________________________________________________________________________________

D. Environmental Exposures:
Home: Type_________________________Attached garage? Yes__No__ How old? _________yrs. How long have you lived there?_____yrs.
City/Suburban/small town/rural?_______________
Type of heating and ventilation system?____________________________________________Washer & dryer location:__________gas/electric?
Hot water heater location?_______gas/electric? Wall-to-wall carpeting? No__.Yes__(which rooms?__________________________________________________________)
Any pets at home? No__Yes__(kind?______________________) Do you use a HEPA room air purifier? No__Yes__(which room(s)_________________________________)
Do you use air conditioning?___No __Yes (which rooms?_________________________________________)

E. Social History:
Do you live alone? Yes__ No__(number of people and relationship ___________________________________)

Smoking habits: cigarette #________/day; Pipe # _____/day;# Cigar #_____/day; Chewing tobacco or snuff? _________/day. # Years smoked/chewed/sniffed?_______
Stopped using tobacco in 19____. Alcohol use: No___Yes___(# glasses wine/beer/liquor/day__________________________________)
Other recreational drug use? No___Yes___(kind_______________________________) Occupation: ______________________________________________
Check the following that apply: __Divorced __Separated __Family problems __School problems __Frequent absence from school/work __Over-anxious

F. Family Medical History: (list all serious medical problems your blood relatives have or died from and what their relationship is to you.)
__ Asthma; __ Allergies; __Tuberculosis; __ Cancer; __ Bleeding problems; __ General anesthesia problems; __ Other _________________________________

SYSTEMS REVIEW

A.General: Eyes __water, __itch __swell, __burn. Ears__drain or feel __blocked, __itchy, __sore. Nose feels __stuffy, __runny, __itchy .
Mouth feels __itchy, __ulcerated, __sore. __Sneeze; __Cough; __Fatigue; __Fever; __Sleep disturbance; __Weight loss (amount ____lbs.); __Night sweats;
__Nose bleeds; __Frequent sore throats; __Frequent colds. __Hoarseness. __Thirst. __Blurred vision.

B.Stomach and Intestines: Appetite __good, __picky, __poor. Bowels __regular, __constipated. Stools __normal, __diarrhea, __solid, __mucus.
__Halitosis; __Swallowing problems; __Choking feeling; __Nausea; __Vomiting; __Indigestion; __Gas; __Bloating; Rectum __irritated, __raw, __painful.

C.Heart and Blood vessels: __ Difficulty breathing; __Chest pain; __Palpitations or irregular heart beat; __Swelling of legs/feet/hands/eyes.

D.Neurological and Skeletal: __Headache (how long ________, onset______, regular__/periodic__/irregular; where does it hurt?_____________________________).
__Ringing noises. __Dizziness. __Lightheadedness; __Joint pains (which ones _________; how often________) __Muscle pains (where?______________________).
__Arthritis (where?____________) __Other (explain_____________________________________________________________________________________________)

E.Skin: __Sores (kind ________________________); __Hives (where?_______________________; how often?_____________________; causes?_________________)
__Rash (what type? _________________________; where?__________________________; causes? __________________________________________________)

F.Genitourinary: Urination: __normal; __problems; __bedwetting; __frequent infections. Menstruation: __normal; __irregular; __severe cramping &/or bleeding.

G. Other __________________________________________________________________________________________________________

THE ANSWERS YOU HAVE PROVIDED WILL HELP DR. MCFADDEN UNDERSTAND YOUR SITUATION AND HELP HER TO DIAGNOSE YOUR MEDICAL PROBLEMS AND RECOMMEND APPROPRIATE TREATMENT FOR THEM WHICH YOU WILL BE ABLE TO FOLLOW.

THANK YOU FOR TAKING THE TIME TO FILL OUT THIS FORM. IF YOU HAVE ANY QUESTIONS, PLEASE DO NOT HESITATE TO ASK THEM AT ANY TIME.