Microsoft word - intake form sinus _english_.doc

299 Ave. Piñero MR#: ________________________ San Juan, PR 00927 Tel. (787) 722-3544 Fax (787) 724-8808 www.prnsi.com NAME: __________________________ _________________ AGE: ________ ADDRESS: ____________________________________________ Name and address of primary care physician and referring physician: 1.________________________________ 2.____________________________________ __________________________________ ______________________________________ __________________________________ ______________________________________ Chief Complaint: _____________________________________________________________________ How long have you noticed this problem? _____________________________________________ Please rate the following symptoms on a scale from 0 (absent) to 4 (severe): Difficulty breathing through nose Is one side worse than the other? Do you have history of nasal allergies or hay fever? Have you had an allergy test done? If yes, to what are you allergic to? _______________________________________________ Have you received allergy shots (immunotherapy)? If yes, for how long? ________________ Have they helped? ___________________ Please rate the effectiveness of the following medications (1=worst, 4=best): Antihistamines (Claritin, Allegra, Zyrtec) Nasal steroids (Flonase, Nasonex, etc.) Oral steroids (Prednisone, Medrol) Which antibiotics have you taken recently? (circle the most effective one) ________________ _____________________________________________________________________________________ The longest period you have been on antibiotics is: How many times have you taken antibiotics in the past 12 months? _____________________ Please mark any medical conditions which apply to you: Cancer – what type? _____________________________________________ Do you have any other medical conditions? ____________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 11. (please include vitamins and herbal supplements) ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 12. I S (please specify medication and type of reaction which occurred) ___________________________________________________________________________________________ ___________________________________________________________________________________________ 13. What is your occupation? ______________________________________________________________ Do you smoke? # of packs/day: ______# of years: ______ If no, did you smoke in the past? # of packs/day: ______# of years: ______ When did you quit? ________________________________ Do you drink alcohol? # of drinks/day: ______# of years: ______ If no, did you drink in the past? # of drinks/day: ______# of years: ______ Have you used drugs or other addictive substances? Yes No What kind? ______________ Have any family members had any of the following medical conditions? (specify relationship) Cancer – what type? _______________________________________ Have they suffered from any other medical condition(s)? _____________________________________ Please mark any symptoms which you have experienced recently: I certify that the above information is true and accurate to the best of my knowledge. I understand that the information is completely confidential. I will not hold the physician or any member of the office responsible for any error or omission on my part while completing this questionnaire. ___________________________________________________________________________________________ Patient Signature ___________________________________________________________________________________________ Physician Signature

Source: http://prnsi.com/doc/intake_form_sinus_en.pdf