Grand Valley ENT & Facial Plastic Surgeons
Toggle navigation
Home
About Practice
Meet Your Providers
Pre-Op
Post-Op
Common Procedures
Links
Patient Forms
Contact Us
Home
Links
Patient Forms
Contact Us
About Practice
Meet Your Providers
Pre-Op
Post-Op
Common Procedures
Patient Forms
New Patients
Falsifying or excluding any information about your medical history may result in your dismissal from the practice.
All fields are required except where marked "(optional)".
PATIENT INFORMATION
First Name
Middle Name or Initial (optional)
Last Name
Date of Birth (mm/dd/yyyy)
Age
Gender:
Male
Female
Address
City
State
Zip
Primary Phone
Other Phone (optional)
Email
Employer (optional)
Work Phone (optional)
Primary Care Provider
Preferred Pharmacy
Pharmacy Location (optional)
RESPONSIBLE PARTY
(IF PATIENT IS UNDER 18 YEARS OLD)
First Name
Middle Name or Initial (optional)
Last Name
Date of Birth (mm/dd/yyyy)
Relationship to Patient
Social Security Number
Address
City
State
Zip
Primary Phone
Other Phone (optional)
Email (optional)
Employer (optional)
Work Phone (optional)
EMERGENCY CONTACT INFORMATION
Emergency Contact Name
Address (optional)
Phone
Relationship to Patient
INSURANCE INFORMATION
Do you have medical insurance?
Yes
No (not insured or self pay)
Primary Insurance
Secondary Insurance
Primary Certificate #
Secondary Certificate #
Primary Subscriber Name
Secondary Subscriber Name
Primary Subscriber DOB
Secondary Subscriber DOB
Primary Subscriber Gender:
Male
Female
Secondary Subscriber Gender:
Male
Female
OTHER INFORMATION
Race:
Select one
Asian
White
American Indian / Native American
Hispanic / Latino
Hawaiian / Other Pacific Islander
Black / African American
More than One Race
Refuse to Answer
Ethnicity:
Select one
Hispanic / Latino
Not Hispanic / Latino
Refuse to Answer
Preferred Language
REASON FOR VISIT
Reason for Visit
Referring Doctor
Primary Care Doctor
When did the problem first appear?
Date of any previous treatment and name of practitioner
MEDICAL HISTORY
Please check any medical problems you have had in the past: (click "None" if no problems)
High blood pressure
Heart disease
Heart attack
Irregular heart beat
Pneumonia
Asthma / COPD
Heart burn / reflux
Radiation to head / neck
Obstructive sleep apnea
Visual loss
Migraines
Head injury
Neck injury
Stroke
Numbness
Seizures
Weakness
Neurological disorder
Cancer
Arthritis
Anemia
Sickle cell
Easy bruising
Easy bleeding
Kidney problems
Liver problems
Thyroid problems
Diabetes
Weight loss
Weight gain
Blood clots
Liver problems
None
Other
Have you had any surgical procedures?
Yes
No
Please indicate the name and date of any surgical procedures you have had:
Have you or anyone in your immediate family ever had a serious reaction to anesthesia?
Yes
No
Please explain:
YOUR CURRENT HEALTH
Are you or could you be pregnant?
Yes
No
Are you currently taking any medications, vitamins or herbs?
Yes
No
Add another
Do you have any drug allergies?
Yes
No
Please list all drug allergies including the name of the drug and the type of reaction:
Are the required immunizations up to date?
Yes
No
Please list the immunizations that need to be completed:
FAMILY HISTORY
Please indicate if any blood relative has had any of the following and indicate the relative:
Cancer
Diabetes
Stroke
Thyroid problems
Hearing loss
Migraines
Bleeding problems
Heart disease
None
SOCIAL HISTORY
Do you smoke?
Yes
No
Have you ever smoked?
Yes
No
Do you drink alcohol?
Yes
No
Do you use recreational drugs?
Yes
No
SYSTEM REVIEW
Please check conditions that apply to your
current
health:
General
Fever
Weight loss
Decreased appetite
Excessive fatigue
none of these
Eyes
Wear glasses
Glaucoma
Cataracts
Infections
Injuries
none of these
Ears, Nose, Throat, Mouth
Wear hearing aids
Nose bleads
Congestion
Inability to smell
Sinus
Sinus headaches
Sore throat
Mouth sores
Hoarseness
Difficulty swallowing
none of these
Cardiovascular
Chest pain / angina
High blood pressure
Irregular pulse
Heart murmur
High cholesterol
Swelling hands/feet
Leg pain while walking
Pacemaker
none of these
Endocrine
Diabetes
Thyroid disease
Hormone problems
Increased thirst/urination
Increased appetite
Living will
Advanced directives
none of these
Respiratory
Asthma
Emphysema
Bronchitis
Chronic cough
Shortness of breath
Pneumonia
Bloody sputum
Lung cancer
Tuberculosis
none of these
Gastrointestinal
Regular nausea/vomiting
Blood in vomit
Heartburn
Gallbladder problems
Hernia
Abdominal pain
Ulcer/gastritis
Change in bowel habits
Liver disease
Jaundice
Diverticulitis's
Irritable bowel / colitis
Hemorrhoids
Colon cancer
none of these
Genitourinary
Urinary tract infection
Painful urination
Blood in urine
Loss of bladder control
Kidney stones
Sexually transmitted disease
none of these
Males
Prostate problems
none of these
Females
Menstrual flow irregular
Menopause
Uterine/cervical cancer
Breast pain
none of these
Use birth control
Allergic/Immunologic
Food allergies
Inhalant allergies
Immune disorders
none of these
Hematological/Lymphatic
Anemia
Bleeding tendencies
Phlebitis
Enlarged lymph nodes
Blood transfusion
none of these
Musculoskeletal
Back/neck pain
Arm/leg pain
Joint pain/swelling
Arthritis
Broken bone(s)
Osteoporosis
none of these
Integumentary
Skin disease
Rashes
none of these
Neurological
Fainting / blackout spells
Seizures
Memory problems
Disorientation/confusion
Concentration problems
Difficulty with speech
Double/blurred vision
Facial weakness
Headaches
Stroke
Muscle weakness
Numbness/tingling
Tremors / hand shaking
Eat salty foods
Eat out frequently
none of these
Submit New Patient Application
