Patient Medical History Questionnaire Posted on April 23, 2025 by Coastal Carolina Otolaryngology Step 1 of 2 50% Coastal Carolina Otolaryngology Patient Name (First)Patient Name (Last)Email Date MM slash DD slash YYYY Medical History Please list all illnesses (e.g., cancer, diabetes, high blood pressure, stroke, heart attack, etc.). Add RemoveSurgical History Please list all of the surgeries that you have had and the approximate date performed. Add RemoveFamily HistoryPlease list all illnesses that run in your immediate family. List maternal or paternal, including grandparents. Add RemoveSocial HistoryDo you currently smoke or use tobacco products: Y N If yes, age started?How much per day?If you are a former smoker, at what age did you start/stop?Do you drink alcoholic beverages?How much in an average week?Allergy HistoryPlease list all allergies (both to medications and environmental allergens) that you have. Add RemoveCurrent MedicationsPlease list all current medications and their dosages if known, or allow us to copy your list. *Include over-the-counter medications. Add Remove3822 Mayfair Street, Myrtle Beach, SC 29577 | Phone: (843) 449-6449 1120 Glenns Bay Road, Suite 117, Surfside Beach, SC 29575 | Phone: (843) 215-1068 Is there a possibility that you may be pregnant? Y N Have you had or do you have hepatitis? Y N Have you had or do you have HIV? Y N Have you had or do you have HIV? Y N Review of Systems: Please answer the following questions regarding how you feel currently. Do you or have you recently had any of the following? EYESVisual changes in the past year? Y N Glaucoma? Y N Double or blurred vision? Y N Pain, redness or dryness? Y N EARSDo you currently wear hearing aids? Y N Date of purchase?Hearing problems? Y N Ringing in the ears? Y N Discharge from the ears? Y N Loss of balance/vertigo? Y N Ear pain? Y N Pressure in the ears? Y N Frequent ear infections? Y N History of loud noise exposure? Y N NOSE Nasal congestion? Y N Nasal discharge? Y N Post-nasal drip? Y N Loss of smell? Y N Frequent nosebleeds? Y N Snoring? Y N Injury to the nose? Y N Nasal or sinus surgery? Y N Frequent sinus infections? Y N THROATSore throat? Y N Frequent throat infections? Y N Painful or difficult swallowing? Y N Hoarseness? Y N HEARTHeart problem? Y N High blood pressure? Y N Angina/chest pain? Y N CHESTAsthma? Y N Bronchitis? Y N Shortness of breath? Y N Wheezing? Y N Chronic cough? Y N History of tuberculosis? Y N DIGESTIVEHeartburn/ulcers? Y N BLOODAnemia? Y N Easy bruising? Y N Received transfusions? Y N The above information is true and correct to the best of my knowledge.Printed Name (Signature):Date MM slash DD slash YYYY
