Bechara Y. Ghorayeb, MD                                                                                                        www.houstonoto.com
OTOLARYNGOLOGY - HEAD AND NECK SURGERY                                                               
1140 Business Center Drive, Suite 560, Houston, Texas 77043                                                        Tel:  (713) 464 2614     Fax:   (713) 464 0729                                                                                              
                                                                                            
                                                                                                                                                                                          
PATIENT NAME:_____________________________________________________ DATE :_______/________/________

DOB:______/______/_____________    WHO REFERRED YOU?_____________________________________________
CHIEF COMPLAINT
PAST HISTORY
Have you ever had any of the following surgeries?
Please describe why you are seeing the doctor today_______________________________________________________
How long have you had this problem? ______________days____________months__________years__________
Have you ever had any of the following? (please check all that apply)
_________________________________
SOCIAL HISTORY
Do you smoke?
If yes, how many cigarettes per day?_______
If no, when did you quit?_________________
Do you drink alcohol?
Have you had or do you have a problem with drugs?
Occupation________________________ Have you been exposed to loud noise?
CURRENT MEDICATIONS
Name of medication
Dose
Reason for taking
ALLERGY TO MEDICATIONS:_________________TO:______________________________________________________
ALLERGY TO LATEX
The above information is to the best of my knowledge.
Patient's signature:_______________________________Date: ______/______/____________
TODAY, DO YOU HAVE ANY OF THESE SYMPTOMS?
EARS:
NOSE:
THROAT:
LARYNX:
NECK:
NEURO:
SKIN:
THYROID:
PARATHYROID:
FAMILY HISTORY
(type______________)
__________________________________________________________________________________________________
PLEASE FILL  OUT THE BACK OF THIS FORM
Hyperthyroidism
Coronary artery stents
Carotid artery surgery
Anemia
Thyroid cancer
High blood pressure
Depression
T & A
Heart failure
Abnormal heart rhythm
Heart attack
Stroke
Heart murmur
Seizures
Coma
Paralysis
Brain tumor
Brain surgery
Bell's palsy
Fainting spells
Asthma
Tuberculosis
Lung cancer
COPD / Emphysema
Stomach / duodenal ulcer
Gall bladder disease/ stones
Acid reflux / heartburn
Kidney failure
Intestinal disease
Kidney stones
Kidney infection
Prostate enlargement
Prostate cancer
Ovary or uterus cancer
Are you pregnant?
Hepatitis B
Liver disease / jaundice
Hepatitis C
Intestinal cancer (type_________)
Breast cancer
Bleeding tendency
Leukemia
Lymphoma
Hypothyroidism
Goiter
Prostatitis
Difficulty urinating
Kidney cancer
Bladder surgery
Blood in the urine
Blood in the sputum
Pacemaker
Diabetes (type____)
HIV
Bipolar
PE tubes /Ear tubes
Septoplasty
Sinus surgery
Open heart surgery
Gall bladder surgery
Thyroidectomy
Mastectomy (breast)
Neck spine surgery
Hysterectomy
Circumcision
Wisdom teeth extracted
Knee / elbow/ hip surgery
Mastoidectomy (ear)
Grafted eardrum
Other surgery___________
Prostatectomy /TURP
Tonsillectomy
Nasoplasty
Back spine surgery
Tubes tied
ANY COMPLICATIONS?
Autism
Mental retardation
Speech delay
Schizophrenia
Difficulty swallowing
Pain on swallowing
Cough
AIDS
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Never smoked
Yes
No
Date of last menstrual period____________
Hearing loss
Ear pain
Ringing
Head noise
Vertigo
Dizziness
Loss of equilibrium
Nausea
Ear drainage
Nasal congestion
Nosebleeds
Nasal drainage
Sinus pain
Pressure in the ear
Sinus headache
Sore throat
Difficulty in swallowing
Lump in the throat
Change in voice
Pain on swallowing
Hoarseness of voice
Coughing blood
Shortness of breath
Snoring
Do you wake yourself up snoring?
Do you stop breathing?
Are you always sleepy?
Neck mass / lump
Neck pain
Choking
Headache
Double vision
Blindness / loss of vision
Basal cell carcinoma
Squamous cell carcinoma
Melanoma
Do you have dentures?
Do you grind your teeth?
Goiter
Hypothyroidism?
Hyperthyroidism
Heart palpitations
Nodule
Kidney stones
Osteopenia
Osteoporosis
Bone fractures
Fatigue
"Crickets"
Heart disease
Problems with anesthesia
Bleeding problems
Hearing loss
High blood pressure
Diabetes
Heart disease
Stroke
Cancer