ENT Consultants of Marin Kambridge P. Hribar, M.D. 1963 South Eliseo Drive, Suite A Greenbrae, California 94904 Patient Name Last Date of Birth _/ Recent Height Mailing Address city State zip Home phone # Cell phone # Emai appointment reminders © patient portal © Isit ok to leave a voice message? Yes. c Noo Ifyes which number? home/cell/work Social Security Number (last 4 digits is fine) Employer Occupatio ‘Work Address City State___ Zip Marital Status: 5 Single OMarried Divorced co Widowed Emergency contact Phone # Relationship to patient. Referring Physician Primary Care Physician Preferred Pharmacy (namescity), Race Preferred Language O English O Other. Tunderstand that my privacy is protected and I understand I have the right to request a copy of the Private Policy for ENT Consultants of Marin. O YES understand that Iam financially responsible forall ofthe charges whether or not paid for by my health insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits not paid by Insurance. T hereby authorize the doctor to release all information necessary to secure the payment ofthe benefits. Sign Date: TURN PALE OVER,ENT Consultants of Marin Kambridge P. Hribar, M.D. 1363 South Eliseo Drive, Suite A Greenbrae, California 94904 Reason for today’s visit? Personal Medical History: Please list past and current medical problems. ‘Surgical History: Please list surgeries you have had and the approximate year. Family Medical History: Please list any significant medical conditions affecting family members. Drug Allergies: Please list any medication you have had a reaction to. ‘Name of Medicine Reaction Name of Medicine Reaction Medication List: Name Dove Frequency Name Dose __ Frequency Doyousmoke? O Yes ONo tyes: packs per day? ‘Number of Years Did you smoke? O Yes ONo Ifyes: packs per day? Number of Years Do you drink alcohol? Yes No Ifyes, how many drinks do you have per week? Do you take drugs? Q'Yes_ QNo If yes, what and how often? How much caffeine do you have each day? Flu shot? O¥es ONENT Consultants of Marin Kambridge P. Hribar, M.D. 1363 South Eliseo Drive, Suite A Greenbrae, California 94904 REVIEW OF SYMPTOMS: ‘General: weight change, change in strength or exercise tolerance Yes O1No ‘Head: headaches, vertigo, injury OYesONo Eyes: vision changes, double of vision, eye pain O¥es O1No ‘Breast: noted lumps, tenderness, swelling, nipple discharge O¥es O1No Chest: difficulty breathing, wheezing, coughing up blood, cough OYesONo ‘Heart: chest pains, palpitations, fainting Yes ONo Abdomen: change in appetite, difficulty swallowing, abdominal pains, blood in stool © Yes O No Genitourinary: urinary urgency, difficulty urinating, change in nature of urine Yes 0 No Gynecology: change in menses, vaginal discharge, pelvic pain (if female) OYesO No Musculoskeletal: pain in museles/joints, imitation of range of motion, numbness) Yes No Neurologic: weakness, tremor, seizures, changes in mentation O Yes O No ‘Psychiatrie: depressed, changes in sleep habits, changes in thought content OYes ONo Other: