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Midwest sinus center - university head and neck associates

_______________________________________________________________ MidWest Sinus Center - University Head and Neck Associates
William R. Panje, M.D. ~ Robert M. Bumsted, M.D. ~ Neal M. Lofchy, M.D.
Joseph P. Allegretti, M.D. ~ Jay M. Dutton, M.D.
Dear Patient: Thank you for scheduling an appointment with our group. We have enclosed some pre-appointment paperwork for you to complete. It is important that you bring this completed paperwork with you to your visit. Please note: All co-pays are collected at the time of your visit before you see the physician. For your convenience, we accept cash, check, MasterCard and Visa. Also, please bring the following items with you to your visit: Insurance Card(s) Drivers License Referral Form, if needed List of all Medications presently being taken Copies of recent CT/MRI scans Your appointment is with Dr. _____________________ on _______________________________________ day at ____________________in our __________________________ office. time / am or pm Thank you and we look forward to seeing you soon. ___________________________________________________________________ URL: http://www.midwestsinuscenter.com

Rush-Presbyterian-St. Lukes Medical Center

Ingalls Family Care Center
Oak Brook Center
MIDWEST SINUS CENTER - UNIVERSITY HEAD & NECK ASSOCIATES
PATIENT INFORMATION [ ]NEW [ ]UPDATE
LAST NAME: ___________________________ FIRST NAME: _________________________ M. I.: ____________ SOCIAL SECURITY #: _________________________ DATE OF BIRTH: _________________ GENDER: ______________ STREET ADDRESS____________________________ CITY ______________________ STATE _____ ZIP ____________ HOME PHONE ________________________ STATUS __________ PHONE # ________________________________ EMPLOYER _________________________ OCCUPATION ______________ PHONE # _____________________ SPOUSE’S NAME _________________________ EMPLOYER _________________ PHONE # _______________________ PRIMARY INSURANCE
SECONDARY INSURANCE
NAME ________________________________________ NAME _________________________________ INSURANCE __________________________________ POLICY # ____________________________________ GROUP # ____________________________________ TO VERIFY ___________________________________ EMERGENCY INFORMATION (IN THE EVENT OF AN EMERGENCY PLEASE NOTIFY)
NAME ________________________________________________________ RELATIONSHIP ______________________________________ ADDRESS _____________________________________________________ HOME PHONE _______________________________________ BUSINESS PHONE # ______________________________________________________ PHONE # ____________________________________________ HOW WERE YOU REFERRED OR HOW DID YOU FIND OUR PRACTICE? [ ] FRIEND/RELATIVE (NAME) _______________ [ ] PHYSICIAN/HOSPITAL (NAME) _____________________________ [ ]NEWSPAPER/MAGAZINE (NAME)__________________ [ ] OTHER ___________________________________ I HEREBY AUTHORIZE PAYMENT OF MEDICAL BENEFITS DIRECTLY TO THE TREATING PHYSICIAN. I
UNDERSTAND THAT I AM RESPONSIBLE FOR ANY PORTION OF MY BILL NOT COVERED BY MY INSURANCE
INCLUDING BUT NOT LIMITED TO ANY APPLICABLE CO-PAYS AND OR DEDUCTIBLES.
X_______________________________________________________________________________________
PATIENT
GUARDIAN
SIGNATURE
I HEREBY AUTHORIZE THE TREATING PHYSICIAN TO RELEASE ANY INFORMATION REQUIRED IN THE COURSE OF MY TREATMENT TO MY
INSURANCE COMPANY

X________________________________________________________________________________________________
PATIENT

GUARDIAN
SIGNATURE

I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THIS OFFICE’S “NOTICE OF PRIVACY PRACTICES” & “AUTHORIZATION FOR USE OR
DISCLOSURE OF HEALTH INFORMATION.”

x_______________________________________________________________________________________
PATIENT
GUARDIAN
SIGNATURE
MIDWEST SINUS CENTER -
UNIVERSITY HEAD AND NECK ASSOCIATES

We would like to be able to correspond with your primary care
physician and any other referring physicians who might be
instrumental in your professional health care. Please supply us with
the names and addresses of your medical doctors:

PATIENT NAME: __________________________________________________

PRIMARY CARE PHYSICIAN:

NAME: __________________________________________________________
ADDRESS: _______________________________________________________
CITY: _________________________ STATE: _______ ZIP CODE: __________
PHONE: ___________________________ FAX: _________________________
CONTACT PERSON: ______________________________________________
REFERRING PHYSICIAN:

NAME: __________________________________________________________
ADDRESS: _______________________________________________________
CITY: _________________________ STATE: _______ ZIP CODE: __________
PHONE: ___________________________ FAX: _________________________
CONTACT PERSON: ______________________________________________
OTHER PHYSICIANS SEEN IN THE PAST YEAR:

NAME: _________________________ PHONE/CITY: _____________________
NAME: _________________________ PHONE/CITY: _____________________
MIDWEST SINUS CENTER - UNIVERSITY HEAD AND NECK ASSOCIATES

MEDICAL HISTORY QUESTIONNAIRE
Page 1
PATIENT NAME: _______________________________________________
WHAT ARE YOU BEING SEEN FOR TODAY? ____________________________________________________ HOW LONG HAVE YOU HAD THIS PROBLEM? ___________________________________________________ WHO IS YOUR REFERRING DOCTOR? _________________________________________________________ • DO YOU HAVE ANY SENSITIVITY OR ALLERGIC REACTIONS TO ANY MEDICATIONS OR FOODS? • IF YES, PLEASE LIST THE NAME OF EACH AND YOUR TYPE OF REACTION: 4. ____________________________ 7. _____________________________ 5. ____________________________ 8. _____________________________ 6. ____________________________ 9. _____________________________ • DO YOU HAVE ANY IMPLANTS SUCH AS AN ARTIFICIAL HEART VALVE OR HIP PROSTHESIS? □ NO IF YES, WHAT TYPE? ______________________________________________ • PLEASE LIST ANY SURGERIES OR HOSPITALIZATIONS YOU HAVE HAD: SURGERY / REASON FOR HOSPITALIZATION DATE COMPLICATIONS • PLEASE LIST ANY OTHER MAJOR ILLNESSES AND/OR INJURIES: __________________________________ • PLEASE LIST YOUR CURRENT MEDICATIONS. INCLUDE ANY BIRTH CONTROL PILLS, STEROIDS, ANY OVER-THE-COUNTER MEDICATIONS OR ANY RECREATIONAL DRUGS MIDWEST SINUS CENTER - UNIVERSITY HEAD AND NECK ASSOCIATES

MEDICAL HISTORY QUESTIONNAIRE
Page 2
PATIENT NAME: _______________________________________________
DATE: ________________________

FAMILY HISTORY
PLEASE CIRCLE ANY MEDICAL PROBLEMS THT RUN IN YOUR FAMILY (GRANDPARENTS, PARENTS, SIBLINGS, OR CHILDREN)
DIABETES ARTHRITIS PROBLEMS WITH ANESTHESIA

SOCIAL HISTORY
WHAT TYPE OF WORK DO YOU DO? __________________________________________________________ DO YOU CURRENTLY DRINK OR HAVE YOU EVER USED ALCOHOLIC BEVERAGES IN THE PAST? □ NO IF YES, WHAT? _______________ AMOUNT? __________HOW OFTEN? __________ LAST TIME DO YOU USE / OR HAVE YOU USED TOBACCO IN ANY FORM? IF YES, WHAT? ___________ AMOUNT? ________HOW OFTEN? __________ LAST TIME USED? _________ ARE ALL IMMUNIZATIONS UP TO DATE? □ YES IS THE CHILD EXPOSED TO TOBACCO SMOKE IN THE HOME OR DAYCARE?
REVIEW OF SYSTEMS
ARE YOU CURRENTLY, OR HAVE YOU HAD PROBLEMS WITH:
CONSTITUTIONAL
SWEATS…….….….….….….….….….….….….….….….….….….…… □ FEVERS…………………………………………………………………………. □ WEIGHT LOSS IN THE LAST SIX MONTHS………………………………………………… □ WAS THE WEIGHT LOSS INTENTIOAL? …………………………………………… □ EYES
DOUBLE
VISION…………………………………………………………………………………………… INJURIES…………………………………………………………………………………………………… GLAUCOMA………………………………………………………………………………………………… WEARING GLASSES/CONTACTS - DATE OF LAST EXAM: __________………………………… □
EARS, NOSE, THROAT

WEARING HEARING AIDS - DATE OF LAST EXAM: __________………………………………… □ LOSS…………………………………………………………………………………………… PAIN…………………………………………………………………………………………………… INFECTIONS………………………………………………………………………………………… CIRCLE: LEFT RIGHT BOTH ……………………… □ CIRCLE: LEFT RIGHT BOTH ……………………… □ BALANCE PROBLEMS (VERTIGO OR SPINNING) ………………………………………………… □ BLEEDS…………………………………………………………………………………………… CONGESTION…………………………………………………………………………………… □ MIDWEST SINUS CENTER - UNIVERSITY HEAD AND NECK ASSOCIATES

MEDICAL HISTORY QUESTIONNAIRE
Page 3
PATIENT NAME: _______________________________________________
DATE: ________________________
(CONT’D)
NASAL DRAINAGE……………………………………………………………………………………… INABILITY TO SMELL…………………………………………………………………………………… □ PROBLEMS……………………………………………………………………………………… THROATS………………………………………………………………………………………… SORES…………………………………………………………………………………………. HOARSENESS…………………………………………………………………………………………… SWALLOWING…………………………………………………………………………… SEASONAL ALLERGIES (HAYFEVER) ……………………………………………………………… □
CARDIOVASCULAR

CHEST PAIN OR ANGINA - DATE OF LAST EKG: __________ ………………………………… □ HIGH BLOOD PRESSURE……………………………………………………………………………… □ PULSE……………………………………………………………………………………. MURMUR………………………………………………………………………………………… ABNORMAL HEART ANATOMY………………………………………………………………………. □ HAS A PHYSICIAN EVER RECOMMENDED ANTIBIOTICS PRIOR TO SURGICAL PROCEDURES (DENTAL WORK) OR BECAUSE OF A HEART MURMUR OR IMPLANT? … □
RESPIRATORY
ASTHMA……………………………………………………………………………………………………
COUGH………………………………………………………………………………………. EMPHYSEMA……………………………………………………………………………………………… □ SHORTNESS OF BREATH……………………………………………………………………………… □ BRONCHITIS/PNEUMONIA……………………………………………………………………………… CANCER…………………………………………………………………………………………… SPUTUM………………………………………………………………………………………. TUBERCULOSIS………………………………………………………………………………………….
GASTROINTESTINAL

INDIGESTION OR PAIN WITH EATING………………………………………………………………. □ NAUSEA/VOMITING…………………………………………………………………………. □ LIVER DISEASE (HEPATITIS) …………………………………………………………………………. □ JAUNDICE…………………………………………………………………………………………………. ULCERS OR GASTRITIS………………………………………………………………………………… □ COLON OR STOMACH CANCER……………………………………………………………………… □
GENITOURINARY

RECURRENT URINARY TRACT INFECTIONS……………………………………………………… □ BLOOD IN YOUR URINE………………………………………………………………………………. □ PROSTATE CANCER (MALES) ………………………………………………………………………. □ UTERINE OR CERVICAL CANCER (FEMALES) ……………………………………………………. □
MUSCULOSKELETAL

BROKEN BONES - LIST: ____________________ ………………………………………………… □ CHRONIC ARM OR LEG WEAKNESS…………………………………………………………………. □ ARTHRITIS…………………………………………………………………………………………………
INTEGUMENTARY

SKIN CANCER……………………………………………………………………………………………. □ DISEASE……………………………………………………………………………………………. □ MIDWEST SINUS CENTER - UNIVERSITY HEAD AND NECK ASSOCIATES

MEDICAL HISTORY QUESTIONNAIRE
Page 4
PATIENT NAME: _______________________________________________
DATE: ________________________
NEUROLOGICAL

FAINTING SPELLS OR “BLACKING OUT”… ………………………………………………………… □ SEIZURES…………………………………………………………………………………………………. DIFFICULTY WITH YOUR SPEECH…………………………………………………………………… □ FREQUENT HEADACHES OR MIGRAINES…………………………………………………………. □ STROKES…………………………………………………………………………………………………. □
PSYCHIATRIC
ANXIETY……………………………………………………………………………………………………
DEPRESSION……………………………………………………………………………………………. □ OTHER PSYCHIATRIC DISORDER/TREATMENT: ____________________ …………………. □
ENDOCRINE

DIABETES…………………………………………………………………………………………………. □ DISEASE………………………………………………………………………………………. □ URINATION…………………………………………………………………. □ PROBLEMS…………………………………………………………………………………. ARE YOU PREGNANT OR BREASTFEEDING? (FEMALES) ………………………………………. □
HEMATOLOGIC/LYMPHATIC
ANEMIA………………………………………………………………………………………………………
TENDENCIES………………………………………………………. □ PERSISTENT SWOLLEN GLAND OR LYMPH NODES………………………………………………. □ BLOOD TRANSFUSIONS - IF YES, WHEN? _______________ …………………………………. □
IMMUNOLOGIC

IMMUNOLOGICAL DISORDERS (IMMUNE DEFICIENCY) …………………………………………. □ HAVE YOU EVER HAD ANY RADIATION TREATMENT? IF YES, PLEASE EXPLAIN: ___________________________________________________________________ SIGNATURE ___________________________________________ DATE: ____________________________________ (PATIENT/PERSON
RELATIONSHIP TO PATIENT: _______________________________________________________________________
REVIEWING STAFF SIGNATURE
NAME: ____________________________________ SINO-NASAL OUTCOME TEST-16
Below you will find a list of symptoms and social/emotional consequences of your rhinosinusitis. We would like to know more about these problems and would appreciate your answering the following questions to the best of your ability. There are no right or wrong answers, and only you can provide us with this information. Please rate your problems as they have been over the past two weeks. Thank you for your participation. Do not hesitate to ask for assistance if necessary. each item below on how “bad” it is by 1. NEED TO BLOW NOSE
2. SNEEZING
5. POST NASAL DISCHARGE
6. THICK NASAL DISCHARGE
FULLNESS
8. HEADACHE
9. FACIAL PAIN / PRESSURE
10. WAKE UP AT NIGHT
11. LACK OF A GOOD NIGHT’S SLEEP
12. WAKE UP TIRED
13. FATIGUE
14. REDUCED PRODUCTIVITY
15. REDUCED CONCENTRATION
16. FRUSTRATED / RESTLESS/
IRRITABLE
2. Please mark the most important items affecting your health (maximum of 5 items)________________⇑ NAME: ____________________________________ OVERALL, HOW WOULD YOU RATE YOUR HEALTH?
2. PLEASE INDICATE THE OVERALL AMOUNT OF DISTURBANCE OR “BOTHER” THAT YOU EXPERIENCE IN YOUR LIFE AS A RESULT OF YOUR RHIOSINUSITIS PROBLEMS: _____BOTHERED MORE THAN A LITTLE, BUT NOT A LOT 3. HOW LONG HAVE YOU BEEN EXPERIENCING YOUR CURRENT SYMPTOMS?
_____I AM NOT EXPERIENCING ANY SYMPTOMS NOW. _____GREATER THAN 4 WEEKS BUT LESS THAN 6 WEEKS 4. WHAT RHINOSINUSITIS MEDICATIONS OR TREATMENTS ARE YOU USING NOW OR HAVE USED
SINCE DEVELOPING YOUR PRESENT SYMPTOMS? (PLEASE CHECK ALL THAT APPLY)
_____NON-DRUG METHODS (EXAMPLES: STEAM INHALATIONS, WARM PACKS) _____SALINE NASAL SPRAYS, DROPS, OR NASAL EMOLLIENTS. _____”OVER THE COUNTER” DECONGESTANT NASAL SPRAYS OR DROPS (EXAMPLES: (EXAMPLES: BENADRYL, CLARITIN, CLARINEX, ALLEGRA, ZYRTEX) _____BOTH ANTIHISTAMINE AND DECONGESTANT (EXAMPLES: CLARITIN –D, ALLEGRA-D) _____ANTIBIOTICS (EXAMPLES: AMOXICILLIN, ERYTHROMYCIN, CEFTIN, LEVAQUIN, Z-PACK, BIAXIN) _____ORAL STEROIDS (EXAMPLES: PREDNISONE, MEDROL) _____NASAL CROMOLYN SPRAYS (EXAMPLE: NASALCROM) _____NASAL STEROID SPRAYS (EXAMPLES: FLONASE, NASONEX, RHINOCORT) 5. HAVE YOU EVER HAD SINUS OR NOSE SURGERY? IF SO, PLEASE DESCRIBE:

_______________ ______________________________________________________________________
_______________ ______________________________________________________________________ _______________ ______________________________________________________________________ THANK YOU FOR YOUR PARTCIPATON! UPDATE: 3/16/05

Source: http://www.midwestsinuscenter.com/images/newpatientpdf2.pdf

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