Patient Medical History Posted on June 10, 2026 by PDX ENT Patient Medical History Step 1 of 2 50% First Name(Required) Last Name(Required) Email(Required) Date of Birth(Required) Pharmacy Name & Location:(Required) Reason for today’s visit:(Required) Referring Provider/Primary Care Provider :(Required) Past Medical History: check ALL that apply, including past and current diagnoses High Blood Pressure Atrial Fibrillation Asthma Sleep Apnea Acid Reflux Cancer Coronary Artery Disease Bleeding Disorder COPD/Chronic Bronchitis Diabetes Stroke Kidney Failure DVT HIV Hepatitis B or C Heart Attack (MI) Most recent HbA1C (Diabetes): Type & Location (Cancer): Treatment (Cancer): Chemotherapy Radiation Treatment Date (Heart Attack (MI)): Other Medical Problems Not Listed Above: Past Surgeries Pertaining to ENT: include ALL that apply, include the years the surgery was performed Ear Tubes Tympanoplasty Septoplasty Rhinoplasty Tonsillectomy Adenoidectomy Cardiac Stents Heart Surgery Kidney Transplant Skin Cancer Yes No Location of Skin Cancer Mastoidectomy Sinus Surgery Thyroidectomy Gastric bypass or banding Other Surgery not Listed Above: Family History: include ALL that apply Asthma Yes No Asthma (Family Member Affected) Bleeding Disorder Yes No Bleeding Disorder (Type) Bleeding Disorder (Family Member Affected) Hearing Loss Yes No Hearing Loss (Family Member Affected) Problems with Anesthesia Yes No Problems with Anesthesia (Family Member Affected) Thyroid Cancer Yes No Thyroid Cancer (Family Member Affected) Other Cancer (Type) Other Cancer (Family Member Affected) Heart Attack Yes No Heart Attack (Family Member Affected) Stroke before age 60 Yes No Stroke before age 60 (Family Member Affected) Additional Family History: Please list all current medications, including over-the-counter: Do you have any allergies to medications? Yes No If “Yes”, please list allergies below: Date of last pneumonia vaccine Date of last flu vaccine Review of Systems Patient Name(Required) Date of Birth(Required) Height(Required) Weight(Required) Social History: Do you currently use: Tobacco – If so how much per day? Do you currently use: Alcohol – If so how much per day? Are you Employed? (please check one) Yes No Workplace/Employer Marital Status Please check “Yes” or “No” if you CURRENTLY have the following symptoms: ENT Hearing Loss Yes No Facial Pain Yes No Ringing in the ears Yes No Loss of smell Yes No Room spinning dizziness Yes No Postnasal drip Yes No Ear pain Yes No Snoring Yes No Ear discharge Yes No Difficulty swallowing Yes No Runny nose Yes No Pain with swallowing Yes No Problem with nasal breathing Yes No Hoarseness Yes No Itchy nose Yes No Nosebleeds Yes No Lump in neck Yes No Neurologic Headaches Yes No Numbness Yes No Weakness Yes No Blurred Vision Yes No Double Vision Yes No Cardiovascular Chest pain Yes No Irregular Heartbeat Yes No Shortness of breath Yes No Musculoskeletal Joint Pain Yes No Joint Swelling Yes No Limited Mobility Yes No Skin Dry Skin Yes No Concerning Mole Yes No Itchy Skin Yes No General Fever Yes No Recent Weight Loss Yes No Night Sweats Yes No Fatigue Yes No Genitourinary Frequent Urination Yes No Nocturnal Urination Yes No Painful Urination Yes No
