New Patient Form (Adult)

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New Patient Health Survey

Patient Name:*

Date of Birth:*

Sex:*

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

Do you have a thryoid nodule?*

Yes

Have you had allergy shots?*

Yes

Have you ever had a neck/thyroid ultra sound?*

Yes

Do you have asthma?*

Yes

Any skin growths that have changed?*

Yes

Do you have migraines?*

Yes

Alcohol/Drug History

Do you drink alcohol?*

Yes

If yes, when?*

Do you use any street drugs?*

Yes

If yes, what type?*

Smoking History

Do you smoke?*

Yes

If yes, please indicate # packs per day for # year(s)*

Did you quit smoking?*

Yes

If yes, when?*

Are you exposed to second-hand smoke?*

Yes

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

Medication:

Reaction:

Medication:

Reaction:

Medication:

Reaction:

Medication:

Reaction:

Medication:

Reaction:

Medication:

Reaction:

Do you take Aspirin/Aspirin Products?*

Yes

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

If yes, why?*

Are you pregnant (Women only)?*

Yes

If yes, how many months?*

Are you nursing?*

Yes

Are you taking birth control pills?*

Yes

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*

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*

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*

Patient/Guardian Signature:*

By submitting this form I agree to the Terms of Use