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*PLEASE FILL OUT THIS FORM COMPLETELY*
PATIENT INFORMATION

Date of Appt.______________ Male___ Female ____ Age ______ Dr. Requesting today’s appt?_____________________
Minor ___ Single ___ Married ___ Divorced ___ Widow ___ Family Doctor ____________________________
Name __________________________________________________________ Home Phone _____________________________

(First) (Middle) (Last)

Address ________________________________________________________ Cell Phone _______________________________
City _________________________ State _______ Zip Code ________________ Date of Birth ______________________
Employer __________________________________ Work phone:_______________ Soc. Sec # _______________________
Email Address: _____________________________________________________________________________________________

IF PATIENT IS A MINOR (PLEASE FILL OUT)
Mother’s Name _____________________________________ Birth Date ______________ Phone _______________________
Single____ Married____ Divorced____ Widow____ S.S. # ____________________________________
Address ___________________________________________ City _______________ State _____ Zip Code _________________
Employer __________________________________________Work Phone ______________________Cell phone______________
Father’s Name ____________________________________________ Birth Date ______________ Phone __________________
Single ____ Married ____ Divorced ____ Widow____ S.S.# _____________________________________
Address ___________________________________________ City ______________ State ______ Zip Code ________________
Employer __________________________________________Work Phone _______________________Cell phone______________
RESPONSIBLE PARTY (IF NOT THE PARENT OR PATIENT)
Name__________________________________________________ Relationship to patient ______________________________
Birth Date ________________ Soc. Sec. # _____________________ Home Phone ___________________________________
Address ____________________________________ City _________________ State ______ Zip Code __________________
Employer _____________________________________________ Work Phone _____________________________________
INSURANCE INFORMATION

Primary Insurance __________________________ ID # ______________________________ Group # ______________________

Employee Name ___________________________ DOB ________________ Employer __________________________________

Social security #____________________

Secondary Insurance _______________________ ID# ________________________________ Group # ______________________

Employee Name __________________________ DOB _________________ Employer ___________________________________

Social security #____________________
Is the patient covered by any type of Medicaid? Yes ___ No ___ updated 02/16

FINDLAY EAR NOSE & THROAT ASSOC., INC.

SIGNATURE ON FILE

I have received a copy of Findlay Ear Nose & Throat’s Financial policy and understand that I am responsible for the balance of my services not covered by insurance.
I authorize payment direct to my doctor.
I authorize and request Findlay Ear, Nose & Throat release information to my Insurance Company, Referring/Family Doctor and or School.
I have received the Practice’s Notice of Privacy Practices and understand that my protected health information may be used by the Practice as described in the notice.
I have received the Practice’s Financial Policy and agree to the terms.
I authorize treatment, such as a CT scan, Allergy, Audiology or other testing to be performed at Findlay ENT if my doctor and I agree that it is necessary for my healthcare and understand that there will be additional charges.
I authorize my pharmacy to provide a medication list to Findlay Ear Nose & Throat.
Can we leave a message on an answering machine/voicemail regarding your healthcare? YES/NO
Home # _____________________ Cell # __________________ Work # ________________________

Findlay Ear Nose & Throat assumes if a cell phone number is given it is ok to contact you on it.
EMERGENCY CONTACT:
Name: _______________________ Phone: _______________Relationship _______________________

Who do you authorize Findlay Ear Nose & Throat to release information to regarding your healthcare?

(if left blank we will assume that we cannot release to anyone but the patient or legal guardian)
Name: _______________________ Phone: _______________ Relationship: _______________________

Name: _______________________ Phone: _______________ Relationship: _______________________

Name: _______________________ Phone: _______________ Relationship: _______________________

Name: _______________________ Phone: _______________ Relationship: _______________________

PATIENT NAME _________________________________ DATE OF BIRTH ____________


SIGNATURE____________________________________ DATE ________________


History & Physical
Name:_________________________________ Date of Birth:_______________ Date of Appointment:_______________
Family Doctor:_______________________ Doctor Requesting Consult:_______________________________________
Please List Drug/Environmental/Food Allergies:

Allergy (Drug/Food/Environment)

Reaction

Allergy (Drug/Food/Environment)

Reaction

Allergy (Drug/Food/Environment)

Reaction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Please List ALL Surgical History

Surgical History

Year

Surgical History

Year

Surgical History

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Alcohol Use:

Currently Drinks Alcohol_______ Only In The Past _______ Has Never Drank Alcohol _______

How Many Years________ How Many Per Week_______ Drinks Rarely_______

Tobacco History:

Current Smoker_________ Former Smoker________ Never Smoked_________ Tobacco Exposure________

How Much_______Day How Many Years ______

Recreational Drug Use:

Has Never Used Illegal Drugs _______ Currently Uses_______ Only In the Past_______

How May Years _______ Type Used ______________________


 

YES

NO

 

YES

NO

 

YES

NO

Heart Disease

 

 

Eczema

 

 

Anemia

 

 

Cardiac Birth Defects

 

 

Sleep Apnea Diagnosed

 

 

Arthritis

 

 

Heart Murmur

 

 

Seizures

 

 

Blood Clots

 

 

Heart Bypass

 

 

Diabetes

 

 

High Cholesterol Levels

 

 

Angina

 

 

Hepatitis

 

 

Bronchitis

 

 

Heart Attack

 

 

Hyperthyroidism

 

 

Pneumonia

 

 

Coronary Artery Stents

 

 

Hypothyroidism

 

 

Cancer

 

 

Pacemaker

 

 

 

 

 

Type:

 

 

Defibrillator

 

 

Previous Problems With Anesthesia

 

 

Irritable Bowel Disease (IBS)

 

 

Aneurysm

 

 

Acid Reflux

 

 

Kidney Disease

 

 

Type:

 

 

AIDS/HIV

 

 

Kidney Infections

 

 

High Blood Pressure Diagnosed

 

 

Rheumatic Fever

 

 

Migraines

 

 

Diagnosed Bleeding Disorder

 

 

Prostate Disease

 

 

Other Important Medical

 

 

Asthma

 

 

Received Blood Transfusions

 

 

Conditions:

 

 

Croup

 

 

Tuberculosis

 

 

 

 

 

COPD

 

 

Ulcers

 

 

 

 

 

Emphysema


























Employment:

Currently Employed_______ Currently Unemployed_______ Retired______ Student_______ Other _______

Marital Status:

Single_______ Married_______ Divorced_______ Widow_______
Family History: (Mother/Father/Brother/Sister/Maternal Grandparents/Paternal Grandparents)

Family History Unknown:___________ Adopted: __________


Family History

YES

NO

Who

Bleeding Disorders

 

 

 

Malignant Hyperthermia

 

 

 

Diabetes

 

 

 

Tuberculosis

 

 

 

Cancer

 

 

 

High Blood Pressure

 

 

 

Low Blood Pressure

 

 

 

Stroke

 

 

 

Kidney Disease

 

 

 

Heart Disease

 

 

 

Other

 

 

 


Pediatric Patients (Ages 0-13)

Exposure to Smoke_______ Any Birth or Delivery Complications________________________________________

Was This Child Nursed_______ Immunizations Up To Date_______

Does This Child Attend Daycare_______ Goes To A Sitter _________ How Many Children Are They Around______


Please fill the forms out and mail them back, email forms@findlayent.com or fax (419-424-3424) prior to your appointment. This allows us to get the information into the computer and better serve you at your appointment time.

Please make sure to bring a photo ID, your insurance card, and co-pay with you for your appointment.

Thank you and if you have any questions please contact us at the Findlay office 419-424-1393 or 888-424-1368 or the Tiffin Office at 419-443-1481

MEDICATIONS LIST Date___/____/____
Name ________________________________________________ Date Of Birth ______________
Approximate Height ___________ Weight ___________
Local Pharmacy _________________________________ Pharmacy Phone _________________
Mail In Pharmacy ________________________________ None ______
Drug Allergies _________________________________________________________ None ________




MEDICATION

DOSAGE

(mg)

HOW OFTEN DO YOU TAKE MEDICATION

























































































































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