Dr. Scott Pargot, DO
Dr. Nathan Sanders, DO
Patient Name_______________________________
Age_____Date of Birth_________
Preferred Pharmacy______________
Referring Physician___________________ Primary Care Provider______________________________________
CURRENT MEDICAL CONDITION
What current problems are you experiencing? Describe your symptoms________________________________ __
_____________________________________________________________________________
______________________________________________Date of Onset of Condition
LIST ALL PREVIOUS SURGERIES
_____________________________________________________________________________
________________________________________________________
PERSONAL MEDICAL HISTORY
□High Blood Pressure
□Stroke
□Heart Problems/CHF
□Cardiac Pacemaker
□Heart Attack/Heart Murmur
□Chronic Ear Infection
□Sinus Surgery
□Septoplasty
□Chronic Sinusitis
□Other
□Tonsillectomy
□History of Ear Tubes
□Asthma
□Allergies/Hay Fever
□Difficulty breathing/wheezing
□Emphysema/COPD
□Arthritis
□Autoimmune Disorder
□Hepatitis
□ Anemia
□Cancer,specify(
)
□HIV or AIDS
□Migraines/Headaches
□Bleeding disorders □Vertigo/Dizziness
□Blood Transfusion □Diabetes
□Chronic Cough
□Snoring/Sleep Apnea/CPAP
□Difficulty Swallowing □Hearing Loss/Hearing Aides
□Acid Reflux/GERD □Liver or Kidney Disease
□Thyroid Problems
□Epilepsy
□Psychiatric Disorders (Depression, Schizophrenia, etc)
ALLERGIES TO MEDICATIONS
Please list any medication allergies including the type of reaction:
MEDICATIONS
Please list all of the medications that you are currently taking (include over the counter and herbal medications)
Medication
Dose
____________________________________ _ _
_ _______________________________ ___
__________________________________
____________________________________
Medication
_
_
___
Dose
FAMILY MEDICAL HISTORY
Please check all the diseases that run in your family
Disease
Mother
Children
Heart Disease
High Blood Pressure
Cancer
Respiratory or Lung Problems
Hearing Loss
Diabetes
Bleeding Disorder
Thyroid Disease
Anesthesia Reaction
Neuromuscular Disease
Other Significant Disease
Father
Grandparent
Sibling
SOCIAL HISTORY
Weight
Height
Do you currently smoke or did you ever smoke?
□Yes □No
□Yes □No
Do you chew tobacco or smoke a pipe or cigar?
If you no longer smoke or chew, when did you quit?
How many drinks of alcohol do you have in a typical week?
If yes, Packs/Day
Years
If yes, how much per day?
Years