New Patient Form

Virginia Ear Nose & Throat Associates
New Patient Form

Please fill out the following form carefully, and submit it to us online prior to your first appointment.

This is a secure form. Your information will remain protected and encrypted. Click the "lock" icon to view our security certificate. If you prefer to print the form and bring it to us in person, click here. You may also view our privacy policy.

Patient Information Full Name: Date of Birth: Sex:

Address: Unit #: City: State: Zip:

Home Phone: Work Phone: Cell Phone:

SSN: Referring Physician: Primary Physician:

Email: *

Race: Ethnicity:

Preferred Language

Emergency Information Emergency Contact: Phone: Relationship:

Guarantor Information (Person Responsible for the Bill) Same as Patient

Full Name: Date of Birth: Sex:

Address: Unit #: City: State: Zip:

Home Phone: Cell Phone: Work Phone:

Employer:

Employer Address: City: State: Zip:

Insurance Information Primary Insurance: Policy ID: Group#:

Group Name:

Policyholder: Date of Birth: Sex: SSN:

Secondary Insurance: Policy ID: Group#:

Group Name:

Policyholder: Date of Birth: Sex: SSN:

Patient History Please state the reason for your visit:

If this visit is related to Dizziness or Vertigo, please also complete this Dizziness/Vertigo Pre-Visit Evaluation Form
and bring it with you on the day of your appointment.

Medication Allergies (please list ALL) None

Family Medical History - Does anyone in your family have any of the following?

Do Not Know None

Allergies
Bleeding Trouble
Heart Disease
Anesthesia Difficulty
Diabetes
Throat Cancer
Asthma
Hearing Loss

Medical & Surgical History: (Please list ALL medical problems & previous surgeries) None

If you are over 65, have you ever had a Pneumonia Vaccine?	Yes	No	N/A
If you are over 50, have you ever had the Flu Vaccine?	Yes	No	N/A
If you are a woman 40 - 69 years old, have you had a mammogram in the past year?	Yes	No	N/A

Social History:

Cigarettes - Never Smoked	Yes	No
Former Smoker:	Yes	No	Year Began Year Quit
Current Smoker:	Yes	No	Packs Per Day Year Began
Other Tobacco:	Yes	No	Amount Per Day Year Began Year Quit
Alcohol:	Yes	No	Drinks Per Week
Caffeine:	Yes	No	Drinks Per Week
Day Care Participation:	Yes	No	Explain
Cigarette Smoke Exposure:	Yes	No	Explain

Current Medications: (Please list ALL)

None

Review of Systems - Please place a check mark beside ALL items that pertain to you.

General
Prematurity
Late Development
Eating Disorders
Fever
Anorexia
Fatigue
Significant Weight Change

Skin
Skin Cancer
Change in Wart/Mole

Eyes
Double Vision
Blurred Vision
Eye Pain

Respiratory
Asthma
Chronic Cough
Sleep Apnea
Snoring Cardiovascular
Murmur
Heart Defect
Irregular Heart Beat
Shortness of Breath
Hypertension
Chest Pain
Leg Pain and/or Swelling

Neurological
Meningitis
Facial Pain
Seizures
Dizziness
Headaches
Auras
Stroke
Fainting Endocrine
Diabetes
Failure to grow
Thyroid Problems

Gastrointestinal
Heartburn, Reflux
Vomiting
Difficulty Swallowing

Genitourinary
Pregnant, currently
Absence of Menstruation
Prostate Problems

Hematology
Abnormal Bleeding
Anemia
Blood Clots
Nose Bleeds

Pharmacy of Choice: (include name and location)

May we contact you via email with periodic health information, announcements or patient surveys?
Yes No *Make sure you filled out your email address above. We will not give out your address or use it unecessarily.

How did you hear about Virginia ENT?

Family Medical History - Does anyone in your family have any of the following?
Do Not Know	None