OUR PRACTICE    OUR STAFF    PATIENT EDUCATION    PATIENT SERVICES    MEDICAL LINKS 


Schedule an Appointment
Patient Registration & History Forms
Prescription Refills
Dizziness Information
Allergy Information
Post-Operative Instructions

 

     

 

 

101 Darling Avenue, Waycross GA  31501, 912-287-1297 


 

Initial History Form

Patient name:

Date of Birth:

Main reason for today’s visit (Describe briefly the illness and its duration):

Present Medications (including the strength and frequency): (Include over-the-counter medications also):

Allergies to medications:
Yes No

If yes, list:

Symptoms Review:
Choose any of the following symptoms you are experiencing now or in the recent past:

Ears:

Yes No
pain
drainage
stuffiness
hearing loss
ringing
dizziness

Nose and Sinuses:

Yes No
headache
facial pressure or pain
pressure around/behind eyes
nose bleed
nasal discharge
postnasal drip
nasal stuffiness & obstruction
snoring
cough
poor smell and taste
excessive sneezing
Itching inside nose, eyes, red eyes, etc.

Throat

Yes No
sore throat
hoarseness
difficulty swallowing
bleeding from mouth/throat

General:

Yes No
loss of weight
poor appetite
fatigue
fever
chills
night sweats

Skin:

Yes No
rashes
hives
easy bruising

GI:

Yes No
heartburn
belching
nausea
vomiting
diarrhea
constipation

Cardiovascular:

Yes No
chest pain
palpitation
swollen feet

Resp:

Yes No
cough
wheezing
shortness of breath
daytime sleepiness
snoring

Neuro:

Yes No
blurred vision
double vision
slurred speech
weakness
tingling or numbness of face or extremities

GU:

Yes No
frequent urination
burning urination
blood in the urine

Past Medical Conditions:

(Choose any of the following medical conditions diagnosed at present or in the past):
diabetes
high Blood Pressure
heart problem
lung problem
asthma
kidney failure
bleeding or coagulatin disorder
TB
hepatitis
glaucoma, seizures, stroke, etc.

Any other medical diagnosis:

Previous Surgical Procedures:
Yes No

If yes, list the name and date of the Procedure starting from the most recent:

Hospitalization in the past:
Yes No

If yes, list the diagnosis and date starting from the most recent:

Social History:

Tobacco (Smoke) including in the past:
Yes No

If yes, how much and how long:

Tobacco (chew) including in the past:
Yes No

If yes, how much and how long:

Alcohol use (including in the past):
Yes No

If yes, what kind, how much and how long:

Substance abuse (including in the past):
Yes No

If yes, give details:

Occupation:

Exposure to noise (including in the past):
Yes No

If yes, give details:

Please list any pets at home:


        
  Home    Login    Contact Us    Privacy    Disclaimer 
< BODY>