ENT History taking

Name:--------------------------------------------------------------------------------------------- Age:------------------- Sex---------------- Residence-----------------------------------------------------Occupation:----------------------------------------------------------------------------- Marital status------------------------------------------------------------------------------------------------------------Smoking-----------pack year, Alcohol ------------------ units or occasionally,
1 What is the reason for your visit today ? complaint?
________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Ear
Onset
2 Do you have hearing loss?

Yes

[ ]

No [ ]

3 Do you have ear pressure ? Yes

[ ]

No [ ]

4 Do you have ear drainage?

[ ]

No [ ]

Yes

Course

..
.
.

Duration

Rt

5 Did you have recurrent ear infections as a child?
Yes [ ]
No [ ]
How many ear infections have occurred in the last 12 months ? ____________________________
6 Do you have ring ing or buzzing in your ears?
7 Do you have dizziness ?

Yes [ ]

No [ ]

Y [ ] N [ ]the following describes it:

8 Does your family have a history of hearing loss ?

Yes [ ]

[ ] light headedness

..
.
.

Lt

...
.

Both

[ ] a rotatory sensation [ ] a faint sensation.

No [ ]

9 Have you had a lot of noise exposure in your life ( shooting guns, machinery noise, military, etc.) ?

Yes[

]

No [ ]

since

Nose
Onset
10 Do you have obstruction ?

Yes [ ]

11 Do you have nasal drainage Yes [
Down the back of your throat [ ]
What color is it?

]

Course

.. .. ..
. . .

Duration

Rt

No [ ]
No [ ]

through nostrils [ ]

[ ] yellow [ ] green [ ] whitish or [ ] clear

12 Are you having nosebleeds?

Yes [ ]

No [ ]

13 Are you having recurrent sinus infections? Yes [ ]

No [ ]

14 Have you ever had sinus surgery ?

Yes [ ]

No [ ]

15 Do you snore ?

No [ ]

Do you pause and stop breathing when you sleep ?

Yes [ ]

Have you ever broken your nose ?

Yes [ ]

No [ ]

Yes [ ]

No [ ]

Lt

What is your current height ? ___________ Weight ? ___________________
16 Is your sense of smell decreased or absent ?

Yes [ ]

No [ ]

17 Do you have allergies to pollens, molds or to some other source?

Yes [ ]

No [ ]

Have you had allergy desensitization shots in the past ? Yes

[ ]

Do your allergies bother you [

] spring & fall only, or [

] spring only [ ] fall only, [

No [ ]
] all year long ?

Throat
18 Do you have throat soreness now?

Yes [ ]

No [ ]

19 Have you had repeated sore throat or tonsillitis episodes Yes

[ ]

No [ ]

Were they cultured and proven Streptococcal positive ? Yes
[ ] No [ ]
How many episodes of tonsillitis have you had in the last 12 months ?
20 Do you have pain when you swallow ?

Yes

[ ]

No [ ]

When you swallow your food does it go down without problems ?

Yes [ ]

No [ ]

Voice

21 Do you have throat pain when talking ? Yes

[ ]

No [ ]

22 Have you had a change in your voice ? Yes

[ ]

No [ ]

Onset :

insidious [ ]

gradual [ ]

sudden [ ]

Course :

progressive [ ]

regressive [ ]

intermittent [ ]

Since
Has your voice been hoarse ?
Yes
[ ]
No [ ]
23 Have you been short of breath or had '"noisy" breathing during an episode of shortness of breath ?
24 Have you coughed up blood in your sputum or phlegm ?Yes
Past history:
chronic medical problems

DM

asthma

high BP

[ ]

Yes [ ]

No [ ]

No [ ]

kidney disease

Liver

cardiac

stroke

Cancer ---------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Allergy : yes [ ]

No [ ] --------------------------------------------------------------------------------------------------------------------------------------------------------------------

Surgical history: number

type:

date:

Both

slow. arthritis Irritative vs Obstructive symptoms: Micturition . or uncles) had any of the following medical problems? Same condition yes[ ] No [ ] list members:___________________________________ Sudden cardiac death yes [ ] No [ ] list members:___________________________________ Heart disease yes [ ] No [ ] list members:___________________________________ Cancer yes [ ] No [ ] list members & Type_____________________________ Diabetes yes [ ] No [ ] list members:___________________________________ Sickle Cell disease/trait yes [ ] No [ ] list members:___________________________________ Thalaseamia yes [ ] No [ ] list members:___________________________________ Hypertension yes [ ] No [ ] list members:___________________________________ Other serious disease list members:___________________________________ System review Endocrine Psychiatric Neurological Thyroid symptoms: Hyperthyroid . sputum. anxiety Special senses . decreased force of stream Genital Vaginal . orthopnoea. pain. constipation. smell. date of last smear test and result Analysis of systems :------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Alcohol units = Strength (ABV) x Volume (ml) ÷ 1000 = No. palpitations. higher mental function and psychiatric symptoms Eyes visual changes. headache. gravida/para/abortus.Hospitalization : Medication: yes [ ] No[ ] number ------------ reason: name quantity Blood transfusion : yes [ ] No [ ] Childhood illness: yes [ ] No [ ] number date: reason reason date: date Family History Has anyone in your family (parents. double vision. unintentional weight loss. first day of last menstrual period (LMP). terminal dribbling. brothers. joint swelling. PND. shortness of breath. bloating.prefer cold weather. heavy periods. wheeze. faintness. cramping. functional deficit. clots always indicate heavy bleeding). No of packs of cigarettes x duration of smoking in years = --------pack year Doctor name: . thin hair. contraception (if relevant). faints. croaky voice.any changes in sight. sisters. proptosis. poor balance. depressed. bright red blood per rectum (BRBPR. fits. hearing and taste. of units. nausea/vomiting. floaters or "feeling like a curtain got pulled down" (retinal hemorrhage vs amaurosis fugax) . Hypothyroid . exercise intolerance. difficulty swallowing (solids vs liquids). Menses . speech problems. headache. funny turns. menopause. claudication cough.frequency. duration. inability to pass gas (obstipation). pins and needles (paraesthesiae) or numbness. hesitancy. foul smelling dark black tarry stools (melaena). dry heaves of the bowels (tenesmus) Integumentary Musculoskeletal Urinary pruritus. scotomas (blind spots). improves/worsens with activity). Cardiovascular Respiratory Gastrointestinal chest pain. aunts.prefer hot weather. weight loss despite increased appetite. staining of clothes. stiffness (morning vs day long. vomiting blood (haematemesis). eye pain. haematuria. diarrhoea. tremor. palpitations. seizures. heavy or light (ask about excessive use of pads/tampons. limb weakness.incontinence. sweaty. tired. sphincter disturbance. sleep patterns. regularity. menarche. hematochezia). visual disturbances. mood swings. polyuria. dry skin Diabetes: polydipsia depression. diarrhea/constipation. indigestion. dysuria. loss of consciousness. grandparents. nocturia. pain. oligomenorrhoea. rashes pain. oedema. haemoptysis abdominal pain.discharge.

Sign up to vote on this title
UsefulNot useful