Comprehensive History Evaluation

Please complete the following medical history form. This will assist your physician in making your diagnosis and instituting your treatment.

1Patient Information > 2Past Medical History and System Review > 3Authorization Forms > 4Patient Follow Up History & Medication List
Patient Name Patient Name * First Last
Phone Number: Phone Number: * - ### - ### ####
Birthdate: Birthdate: * / MM / DD YYYY
Date Date / MM / DD YYYY
Ear Problems:

Ear Problems: Hearing Loss Dizziness Ringing/Other Noise Drainage Pain Other Other
Nose Problems:

Nose Problems: Blocked Drainage Bleeding Sneezing Lose of Smell Facial Pain Other Other
Throat Problems:

Throat Problems: Sore Throat Difficulty Swallowing Voice Change/Hoarseness Cough Sleep Apnea Snoring Thyroid Other Other
Which of the above is the main problem? *

Which of the above is the main problem? Ears Nose Throat Other Other
Present Medical Illnesses:
Present Allergies to Medication(s): *
Do you have Insurance? *

Do you have Insurance? Yes No
Would you like to upload an image of your Insurance card instead of filling out the information manually? *

Would you like to upload an image of your Insurance card instead of filling out the information manually? Yes No
Front of Primary Insurance Card:

Attach Files
Back of Primary Insurance Card:

Attach Files
Primary Insurance Company:
Policy Number:
Group Number:
Policy Holder Name Policy Holder Name First Last
Policy Holders Birthdate Policy Holders Birthdate / MM / DD YYYY
Social Security Number:
Maximum of 9 digits allowed. Currently Entered: 0 digits.
Do you have a secondary insurance? *

Do you have a secondary insurance? Yes No
Would you like to upload an image of your Insurance card instead of filling out the information manually?

Would you like to upload an image of your Insurance card instead of filling out the information manually? Yes No
Front of Secondary Insurance Card:

Attach Files
Back of Secondary Insurance Card:

Attach Files
Secondary Insurance Company:
Group Number:
Policy Number
Secondary Policy Holder Name Secondary Policy Holder Name First Last
Birthdate: Birthdate: / MM / DD YYYY
Social Security Number:
Maximum of 9 digits allowed. Currently Entered: 0 digits.

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