ENT Clerk Sheet

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
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, grandparents, brothers, sisters, aunts, 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 - prefer cold weather, mood swings, sweaty, diarrhoea, oligomenorrhoea, weight loss despite increased appetite,
tremor, palpitations, visual disturbances. Hypothyroid - prefer hot weather, slow, tired, depressed, thin hair, croaky voice, heavy periods, constipation,
dry skin
Diabetes: polydipsia
depression, sleep patterns, anxiety
Special senses - any changes in sight, smell, hearing and taste, seizures, faints, fits, funny turns, headache, pins and needles (paraesthesiae) or
numbness, limb weakness, poor balance, speech problems, sphincter disturbance, higher mental function and psychiatric symptoms
Eyes
visual changes, headache, eye pain, double vision, scotomas (blind spots), floaters or "feeling like a curtain got pulled down" (retinal hemorrhage vs
amaurosis fugax) , proptosis.
Cardiovascular
Respiratory
Gastrointestinal
chest pain, shortness of breath, exercise intolerance, PND, orthopnoea, oedema, palpitations, faintness, loss of consciousness, claudication
cough, sputum, wheeze, haemoptysis
abdominal pain, unintentional weight loss, difficulty swallowing (solids vs liquids), indigestion, bloating, cramping, nausea/vomiting,
diarrhea/constipation, inability to pass gas (obstipation), vomiting blood (haematemesis), bright red blood per rectum (BRBPR, hematochezia), foul
smelling dark black tarry stools (melaena), dry heaves of the bowels (tenesmus)
Integumentary
Musculoskeletal
Urinary
pruritus, rashes
pain, stiffness (morning vs day long, improves/worsens with activity), joint swelling, functional deficit, arthritis
Irritative vs Obstructive symptoms: Micturition - incontinence, dysuria, haematuria, nocturia, polyuria, hesitancy, terminal dribbling, decreased force of
stream
Genital
Vaginal - discharge, pain, Menses - frequency, regularity, heavy or light (ask about excessive use of pads/tampons, staining of clothes, clots always
indicate heavy bleeding), duration, pain, first day of last menstrual period (LMP), gravida/para/abortus, menarche, menopause, contraception (if
relevant), date of last smear test and result
Analysis of systems :-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Alcohol units = Strength (ABV) x Volume (ml) 1000 = No. of units.

No of packs of cigarettes x duration of smoking in years = --------pack year
Doctor name:

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ENT History taking

3 Do you have ear pressure ? Yes

4 Do you have ear drainage?

5 Did you have recurrent ear infections as a child?

Y [ ] N [ ]the following describes it:

8 Does your family have a history of hearing loss ?

[ ] a rotatory sensation [ ] a faint sensation.

11 Do you have nasal drainage Yes [

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

12 Are you having nosebleeds?

13 Are you having recurrent sinus infections? Yes [ ]

14 Have you ever had sinus surgery ?

Do you pause and stop breathing when you sleep ?

Have you ever broken your nose ?

What is your current height ? ___________ Weight ? ___________________

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

Have you had allergy desensitization shots in the past ? Yes

Do your allergies bother you [

] spring & fall only, or [

] spring only [ ] fall only, [

19 Have you had repeated sore throat or tonsillitis episodes Yes

Were they cultured and proven Streptococcal positive ? Yes

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

21 Do you have throat pain when talking ? Yes

22 Have you had a change in your voice ? Yes

Surgical history: number

Sudden cardiac death

list members & Type_____________________________

Sickle Cell disease/trait

Other serious disease

Alcohol units = Strength (ABV) x Volume (ml) 1000 = No. of units.

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What is your current height ? _ Weight ? _________