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Ear, Nose, and Throat Patient Registration Form

Gather medical history and contact details from patients before their visit with an ear, nose, and throat specialist.

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Page 1

Patient Name

Nombre

Apellido

Date

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Gender

Height

Weight

Marital Status

Emergency Contact Name

Nombre

Apellido

Emergency Contact Number

Reason for Your Visit

Past Surgeries (Type and Approximate Year)

Allergies (Environmental, Food, Medications)

Are You Currently Taking Any Medications?

Yes No

If Yes, List All Medications and Dosages (If Known)

Past and Current Medical History (Check All That Apply)

Diabetes Hypertension Heart Disease Asthma Cancer None

Check If You Have Family History of the Following Diseases

Diabetes Hypertension Heart Disease Cancer Hearing Loss None

Check If You Currently Have Any of the Following Symptoms

Ear Pain Hearing Loss Sore Throat Nasal Congestion Dizziness None

Have You Ever Smoked Tobacco?

Yes No

Do You Drink Alcohol?

Yes No

Page 2

Rhinosinusitis Symptom Impact Assessment (Past Two Weeks)

	Column 1	Column 2	Column 3
Row 1
Row 2

Upload Any Previous Medical Records, Including Imaging

Max 10 MB per file

Printed Name

Endoscopy/Audiogram Notice Acknowledgment

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