New Patient Form (Adult) "*" indicates required fields Step 1 of 4 25% New Patient Health SurveyPatient Name:*Date of Birth:* MM slash DD slash YYYY Sex:* M F Tel #:*Email Address* How did you hear about Penn Medicine Becker ENT & Allergy?*Primary care Doctor:*Primary Care Physician's address:*PCP phone number:*Name of pharmacy:*Pharmacy address:*Pharmacy phone number:*Please describe the reason(s) for your visit:* From the list of symptoms below, CHECK the ones you have:NOSE AND SINUS* Allergy symptoms (sneezing, itchy nose/eyes/throat, runny nose). Nasal blockage Postnasal drip Discolored nasal drainage Nasal bleeding Sinus infections Facial pressure Headache or facial pain Snoring/sleep problems Halitosis (bad breath) Decrease in smell or taste Cough Tooth pain Other N/A Other*THYROID/NECK Swollen lymph nodes or neck mass Thyroid nodule EARS Hearing loss/ear fullness Ringing Dizziness Ear infections THROAT/VOICE Heartburn/reflux Hoarseness Difficulty swallowing When did the problem(s) start?*Rate severity of the problem on a scale of 1 to 10*What makes it worse?*What makes it better?*What type of treatments/medications have you received for this/these problems?*Do you have environmental allergies?* Yes No Do you have a thryoid nodule?* Yes No Have you had allergy shots?* Yes No Have you ever had a neck/thyroid ultra sound?* Yes No Do you have asthma?* Yes No Any skin growths that have changed?* Yes No Do you have migraines?* Yes No Alcohol/Drug HistoryDo you drink alcohol?* Yes No If yes, when?*Do you use any street drugs?* Yes No If yes, what type?*Smoking HistoryDo you smoke?* Yes No If yes, please indicate # packs per day for # year(s)*Did you quit smoking?* Yes No If yes, when?*Are you exposed to second-hand smoke?* Yes No Patient Name:*Past Medical History: Please CHECK any of the following medical conditions, if you have ever had them:* AIDS/HIV Alcohol or drug abuse Anemia Angina (chest pain) Asthma Bleeding disorder Cancer Cerebral aneurysm Clotting disorder COPD Coronary artery disease Crohn’s disease Diabetes Emphysema GERD Glaucoma Headache Heart attack (MI) Heart palpitations Heart rhythm disturbance Hypertension Hyperthyroid Hypothyroid Kidney disease Liver disease Lupus Multiple sclerosis Obstructive sleep apnea Osteoporosis Parkinson’s Seizure/epilepsy Sickle cell Stroke Other N/A Other*Past Surgical History: Please CHECK any of the following surgeries/procedures that you have had:* Adenoidectomy Cardiac bypass Cardiac catheterization Chemotherapy Dialysis Inferior turbinate reduction Open heart surgery Organ transplant Pacemaker Radiation therapy Rhinoplasty Septoplasty Sinus surgery Snoring surgery Tonsillectomy N/A List all medications that you are presently taking with the dosage:Medication:Dossage:Medication:Dossage:Medication:Dossage:Medication:Dossage:Medication:Dossage:Medication:Dossage:Medication:Dossage:Medication:Dossage:Are you allergic to any medications?* Yes No Medication:Reaction:Medication:Reaction:Medication:Reaction:Medication:Reaction:Medication:Reaction:Medication:Reaction:Do you take Aspirin/Aspirin Products?* Yes No Family/Social History: Please CHECK any of the listed diseases that run in your family (if none, check “None”):Diabetes Father Mother Brother Sister Heart problems Father Mother Brother Sister Hypertension Father Mother Brother Sister Stroke Father Mother Brother Sister Bleeding tendencies Father Mother Brother Sister Asthma Father Mother Brother Sister Allergies Father Mother Brother Sister Atopic Dermatitis (eczema) Father Mother Brother Sister None Father Mother Brother Sister Other Father Mother Brother Sister Have you been hospitalized in the last 5 years?* Yes No If yes, why?*Are you pregnant (Women only)?* Yes No If yes, how many months?*Are you nursing?* Yes No Are you taking birth control pills?* Yes No I understand the above information is necessary to provide me with surgical/medical care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medications.Patient/Guardian Signature:*Date* MM slash DD slash YYYY Privacy Notice We comply with Federal law, which requires us to maintain the privacy of protected health information, and to provide patients with notice of our legal duties and privacy practices with respect to protected health information.Please list below those individuals with whom we may share your health care information.If you have any questions, please speak with our HIPAA Compliance Officer in person or by phone at our main phone number. I have received a copy of this privacy notice and I both understand and agree to the terms. (Policy can be found in our online forms section).Patient Name (Print):*Date* MM slash DD slash YYYY Patient/Guardian Signature:*Referral Acknowledgement Dear Patient There are many different kinds of health insurance, each of which has its own set of requirements for referrals. While we are happy to help you understand the details of your policy, it is ultimately a patient’s responsibility to know whether or not they need to have a referral. If you do not have a referral for your visit, your insurance company may not pay for the services billed, and the payment will become your responsibility. Please make sure that you have a proper and up to date referral if your insurance plan requires one. Separately, in some cases, your provider may recommend that you undergo an endoscopy during your office visit as a means to better visualize the nose, sinus, and/or throat areas. Your provider will ask for your permission (consent) prior to performing an endoscopy, and will also ask for your permission to suction the nose if needed, and to take a culture if there is drainage that looks like infection. Endoscopy is a separate procedure, it is not included in the price of the office visit and is billed to your insurance company separately from your office visit. To learn more, please visit our website where endoscopy information and consents are available under the “Patient Resources” tab by clicking on “Forms”. I acknowledge that I have read and understand the statement above. It is my responsibility to make sure that I have a referral for evaluation and treatment. Patient Name (Print):*Date* MM slash DD slash YYYY Patient/Guardian Signature:*By submitting this form I agree to the Terms of Use Δ