Robert Ehrhard, D.D.S., M.D., F.A.C.S.

Amy Reising, NP-C

251 S. Truman Rd.
Jasper, IN 47546
(812) 634-6700

Review of ENT Systems

Check all symptoms you are experiencing at this Tme:

❑ Otalgia (ear pain) ❑ Mouth, mass

❑ Otorrhea (ear drainage) ❑ Oral bleeding
❑ Hearing loss ❑ Ulcers
❑ Sound sensi5vity ❑ Tongue swelling
❑ Tinnitus (ringing) ❑ Dizziness
❑ Ears, itching ❑ Ver5go (balance issues)
❑ Nasal obstruc5on ❑ Neck mass
❑ Conges5on ❑ Neck pain
❑ PND (post nasal drip) ❑ Neck s5ffness
❑ Rhinorrhea (runny nose) ❑ New lesion
❑ Loss of smell ❑ Skin, bleeding
❑ Epistaxis (nosebleeds) ❑ Chest pain
❑ Facial pressure ❑ Shortness of breath
❑ Oral pain ❑ Wheeze
❑ Hoarseness ❑ Fa5gue
❑ Cough ❑ Fever
❑ Indiges5on ❑ Night sweats
❑ Heartburn ❑ Weight gain
❑ Dysphagia (difficulty swallowing) ❑ Weight loss
❑ Odynophagia (painful swallowing) ❑ Cold intolerance
❑ Throat pain ❑ Heat intolerance
❑ Hemoptysis (coughing up blood) ❑ Dry hair
❑ Stridor (noisy breathing) ❑ Dry skin
❑ Dry mouth ❑ Blisters
❑ Excessive saliva5on ❑ Rash
❑ Dysphonia (difficulty speaking) ❑ Headache
❑ Foul smell

The above informa5on is accurate and true to the best of my knowledge

Pa5ent Signature ______________________________ Date_________________