Last updated on: 2013-02-07 01:29 AM

South Florida ENT Medical History

Patient Name: Calvin Flowers ll
Patient DOB: 07/06/2010
Past Medical History / Health Conditions
ChieI Complaint / Reason Ior Visit:
sleep problems
HEAD/SINUSES:
NONE
HEAD/SINUSES - II Other - please speciIy:
EARS-HEARING:
NONE
EARS/HEARING - II Other, please speciIy:
NOSE:
CONGESTION,RUNNY NOSE
NOSE - II Other, please speciIy:
MOUTH:
NONE
MOUTH - II Other, please speciIy:
THROAT:
NONE
THROAT - II Other, please speciIy:
RESPIRATORY:
WHEEZING,SLEEP APNEA
RESPIRATORY - II Other, please speciIy:
GI:
NONE
GI - II Other, please speciIy:
NEUROLOGICAL:
NONE
NEUROLOGICAL - II Other, please speciIy:
CARDIOVASCULAR:
NONE
CARDIOVASCULAR - II Other, please speciIy:
GU:
NONE
GU - II Other, please speciIy:
CONSTITUTIONAL SYMPTOMS:
NONE
CONSTITUTIONAL SYMPTOMS - II Other, please speciIy:
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Last updated on: 2013-02-07 01:29 AM
South Florida ENT Medical History
Patient Name: Calvin Flowers ll
Patient DOB: 07/06/2010
EYES:
GLASSES
EYES - II Other, please speciIy:
SKIN:
NONE
SKIN - II Other, please speciIy:
MUSCULOSKELETAL:
NONE
MUSCULOSKELETAL - II Other, please speciIy:
PSYCHIATRIC:
SLEEP DISORDER - SNORING OR APNEA
PSYCHIATRIC - II Other, please speciIy:
ENDOCRINE:
NONE
ENDOCRINE - II Other, please speciIy:
HEMATOLOGIC-LYMPHATIC:
NONE
HEMATOLOGIC - LYMPHATIC - II Other, please speciIy:
ANY OTHER MEDICAL CONDITIONS:
Past Surgical History?
No
Past Surgical History: please list procedure and date Ior each one
Family History oI Medical Problems?
No
Family History oI Medical Problems - Please list and indicate Iamily member:
Are you currently using any tobacco products?
Never
II you are currently using: indicate quantity
II you Quit - how much did you smoke?
II you Quit - Ior how long did you smoke?
Do you consume alcohol?
No
II you consume alcohol - indicate Quantity:
II you consume alcohol - indicate Frequency:
Do you currently have or have you had a problem with substance abuse in the past?
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Last updated on: 2013-02-07 01:29 AM
South Florida ENT Medical History
Patient Name: Calvin Flowers ll
Patient DOB: 07/06/2010
No
Please list all Allergies, including Medication, Environmental, Food, & Latex: II none, please type None.
none
List all medications you are currently taking, including over the counter medications and vitamins: II none, please type None.
children's over the counter daily vitamins
Electronic Signature: By typing your name below, you are certiIying that the inIormation provided on all Iorms are true and accurate to the best oI your knowledge.
nina stuart
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