Stanford sinus center new patient questionnaire

STANFORD SINUS CENTER NEW PATIENT QUESTIONNAIRE

801 Welch Rd., Stanford, CA 94305

INSTRUCTIONS: Please answer all of the questions to the best of your ability before you come to your appointment. All responses will be kept strictly confidential.
1. What is the reason for your appointment?

__________________________________________________________

What problem is bothering you the most?

__________________________________________________________

How long has it been bothering you?

__________________________________________________________

Who are you referred by?

________Self ______Doctor Name___________________________

2. Do you have FACIAL PAIN OR PRESSURE? Y N

If so, please answer the following questions:

a. On which side is your discomfort more prominent? R L Both

b. How severe is it? Mild Moderate Severe

c. Where do you have discomfort? (Check all that apply)

______ Between the eyes

______ Cheeks

______ Around/behind the eye

______ Back of the head

______ Temple

______ Forehead

______ Other: ___________________

d. Has a physician ever diagnosed you with migraines? Y N

e. Can you distinguish your migraines from your sinus pain? Y N
3. Do you have NASAL CONGESTION or BLOCKED BREATHING? Y N
If so, which side is more affected? Right Left Both equally
4. Do you have NASAL DISCHARGE or POST-NASAL DRIP? Y N
How would you describe it? Clear Discolored Bloody
5. How is your SENSE OF SMELL? Normal Diminished Absent

6. Check all of the following symptoms that apply to you:

______ Headache

______ Fever

______ Bad breath

______ Fatigue

______ Dental pain

______ Cough

______Ear pressure

______ Nosebleeds

7. Do you have hay fever or other allergy symptoms? Y N

Have you ever been tested for allergies? Y N When? _______________________

If yes, please list your allergies:________________________________________

Did you receive allergy shots? __________ If yes, how long?_________ Did they help? ______
8. Do you have RECURRENT INFECTIONS? Y N

If so, please list all the antibiotics you have taken for sinus

infections:______________________________________________________________________________________________________________________________________________________________________________________

The longest period of time that you have been on a single antibiotic is:

<2 weeks 2-4 weeks 4 - 8 weeks More than 8 weeks
9. PAST MEDICAL HISTORY

Do you have or have you been treated for any of the following?

____ asthma ____ heart disease ____ high blood pressure

____ gastritis/ulcers ____cancer (type: _________________________________)

____ fibromyalgia ____ stroke ____ osteoporosis ____ low/high thyroid ____ liver disease ____ depression

____ immunodeficiency ____ kidney disease ____ diabetes

____ seizures ____ bleeding disorder ____ cataracts

____ hepatitis (type______) ____ glaucoma

Please list any other health problems not listed above:

________________________________________________________________________

________________________________________________________________________
10. HOSPITALIZATIONS AND OPERATIONS

Date Reason/Procedure Hospital

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
11. CURRENT MEDICATIONS (please include any vitamins or herbal medications)

Name Dose Frequency

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________
12. MEDICATION ALLERGIES

List any medication allergies and the type of reaction that occurs:

________________________________________________________________________

________________________________________________________________________

____ NONE KNOWN
13. FAMILY HISTORY: Please check all that apply to your family members

____ Allergy ____ Sinus disease ____ Asthma

____ Cystic fibrosis ____ Immunodeficiency ____ Bleeding disorder

____ Cancer (Type and relationship of family members: ________________________)

____ Other (List _____________________________________________________________________)
14. SOCIAL HISTORY:

a. Your occupation: ______________________________

b. Do you smoke? Y N If yes, # packs per day? ___/#___ years?

Did you ever smoke in the past? Y N If yes, # packs per day? ___/#___ years?

c. Do you drink alcohol? Y N If yes, # drinks per day? ________

d. Have you ever used any other addictive substances? Y N

If yes, what drug(s)? _______________________________________________________________
15. REVIEW OF SYSTEMS: Please circle any of the health problems that pertain to you.
Ears:

Ringing Dizziness Drainage Hearing loss No Symptoms

Mouth/Throat:

Pain or difficulty swallowing Lumps in Neck

Hoarseness No Symptoms
Cardiopulmonary:

Chest Pain Heart murmur Shortness of breath

Palpitations Cough No Symptoms

Genitourinary:

Burning on urination Frequency of urination No Symptoms

Gastrointestinal:

Heartburn Vomiting Diarrhea

Abdominal pain No Symptoms
Psychological: Depression No Symptoms
Sleep pattern:

Snoring Daytime sleepiness Stop breathing during sleep No Symptoms

Endocrine:

Heat intolerance Cold intolerance Excessive thirst No Symptoms

Eyes:

Recent change in vision Impaired vision Double vision No Symptoms

Neurologic:

Weakness Numbness No Symptoms

Musculoskeletal:

TMJ disorder Arthritis No Symptoms

General:

Nausea Fever Fatigue

Weight gain Weight loss No Symptoms
Skin:

Skin Cancer No Symptoms

Hematologic/Lymphatic:

Swollen Lymph Nodes

Allergic/Immunologic:

Hepatitis Frequent Infections Immune Disorders

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