Check More Than One Where Appropriate.
Date Format: MM slash DD slash YYYY
This will be helpful if you are filling out this form in the days prior to your actual appointment.
Please include the name of the doctor or practice that referred you to our office. If you found Mann ENT from another source, such as a friend or the internet, please let us know.
Please describe in a few words the reason for your visit today, and how long problem has been present.
"Loss of hearing in my right ear for two days" for example.
You may include more than one symptom if this is appropriate.
For each symptom noted above, please indicate the date of onset of this symptom, how long it tends to last, how often it happens, how severe it is on a scale from 1-10 (10 being the worst), any factor that makes it better or worse, and any strongly associated factors.
Please list your medications here if you are a new patient, or any new medications since your last visit if you are a returning patient. You may also include any issues with medications previously prescribed by Mann ENT.
If you are a returning patient, please list any new allergies that have developed since your last visit.
Please indicate any surgical procedures you have undergone since your last visit with us.
Please tell us of any medical condition that has been diagnosed since your last visit.
If you would like to include anything else we should know, please type it here.