HEALTH HISTORY INVENTORY
Gulf Coast Facial Plastics and ENT Center
Dr.
Daniel Daube Dr. James C. Beggs
Patient Name:
________________________________________________________________________
Reason for TodayÕs Visit?
______________________________________________________________
How Did You Hear About Us?
__________________________________________________________
Occupation:
_________________________________________________________________________
Do you live alone? Yes
No
Who Lives With You?
___________________________________
Do you smoke?
Yes, IÕve smoke _______
packs of cigarettes a day for _________ years.
Yes, I smoke cigars or a pipe.
No, I have never smoked.
No, I quite ____years ago. At that time, I was smoking ____ packs
a day for _____years.
Do you drink alcohol?
No, never (or rarely)
No, but I used to
Yes
Daily
1 or more times a week
1 or more times a month
Please list any prior
major illnesses and/or injuries: ________________________________________
_____________________________________________________________________________________
Surgeries/Hospitalizations Year Complications
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Have you ever had any
problems with anesthesia?
Yes
No
|
Current Medication (s) |
Dose |
Frequency |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Allergies to
Medications:________________________________________________________________
Any Known Allergies:
__________________________________________________________________
Are there any medical
problems that run in your family?_____________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Are there any other
medical problems that are not related to this visit that you would like us to
arrange evaluation of: __________________________________________________________________
Please list any other
over-the-counter medications, herbal supplements, and vitamins that you take on
a daily basis:
_______________________________________________________________________
Who is your personal
physician at this time? _______________________________________________
OVER