Microsoft word - sinusques.doc

Gorden T. McMurry, M.D. EAR, NOSE & THROAT Providing Specialized Care For Your Nose and Sinuses Sinus History
(Please check al answers that apply to you -- front and back) Name______________________________________ DOB____________ Worst Problem: Headache/Facial Pain ____ Hard Time Breathing Through Nose ____ Frequent Sinus Infections____ When Did Symptoms First Start? Early Childhood ____Teen____ Adult____ Since (Mo/Yr) ________________ How many days per month ____ How many hours does the usual headache last?_________ Worse in the: Morning____ Afternoon____ Evening____ Constant pain which gets worse____ Severity: Mild____ Moderate____ Severe____ Quality: Dul ____ Sharp____ Throbbing____ Location: Above the eyes____ Below the eyes____ Behind the eyes_____ Between the eyes____ Top of the head ____ Over the cheeks ____ Back of Head ____ Associated Symptoms: Nausea____ Tearing____ Eye symptoms____ Stuffy Nose _____ Do your symptoms worsen with exposure to: Pressure changes____ Cigarette smoke____ Weather ____ Perfumes____ Cleaning products____ Other____ Hard Time BreathingThrough Nose / Mouth Breathing: Does it get worse when you lie down? Yes____ No____ Which side is affected? Right____ Left____ Always____ Sometimes____ Never____ At night____ Poor Sense of Smel ____ Bad Breath____ Frequent Sore Throat____ Taste____ Frequent throat clearing____ Aching teeth____ Hoarseness____ Cough____ Runny with your nose in the morning? Yes____ No____ Number of antibiotic therapies taken in last year?____ Last antibiotic therapy (Mo/Yr)___________ Relief from antibiotic therapies: Very helpful____ Somewhat helpful____ Not very helpful____ Side effects from antibiotics: None____ Al ergies____ Stomach problems____ Yeast Infections____ List al antibiotics taken in last 12 months: _______________________________________________________ Drainage in Back of Throat / Runny Nose: A lot____ Somewhat____ Not much____ Never____ Color: Green____ Yel ow____ White____ Clear____ Trouble Sleeping: None____ Snoring____ Apnea____ Energy Level: Normal____ Low____ Do You Think Your Symptoms Are? Progressive____ Stable____ Affecting quality of life: Yes___ No___ Do you miss work or school due to sinus disease? Yes____ No____ Average number of days missed per year____ Do your sinus or nasal problems affect your life every day? Yes____ No____ Do you think you have: Al ergies____ Asthma____ Eczema____ Hives____ Migraines____ Have you been tested for al ergies? Yes____ No____ If yes, by whom and when ___________________ Yes___ No___ If yes, how long?_________ Did the shots help? Yes__ No__ Over the counter nose sprays (Vicks™, Afrin™, Duration™, or others) Yes ____ No ____ Over the counter antihistamines (Benadryl™, Tavist™, others) Yes ____ No ____ Prescription antihistamines: Yes ___ No ____ Check al that apply: Hismanal__ Claritin__ Al egra__ Zyrtec__ Astelin™__ Prescription nose sprays: Yes ____ No ____ Please list: _________________________________________________ Have you had: Sinus x-rays Yes____ No____ Results: Normal____ Abnormal____ CT Scans Yes____ No____ Results: Normal____ Abnormal____ Where: _________________ Operations: Nasal septal (breathing) surgery: Yes____ No____ When / Dr. Name?________/________________ Relief from surgery: Yes___ No___ A little___ Relief from surgery: Yes___ No___ A little___ Do you feel you are miserable with sinus problems? Yes___ No___ Do you feel you have received enough medicines for your sinus problems? Yes____ No____ Have you or any one of your family experienced problems with surgical bleeding or anesthesia? Yes ___ No ___ If so,explain: ______________________________________________________________________________________ _________________________________________________________________________________________________ SYMPTOM HISTORY
Grade each symptom from 1-10 with 10 being the worst and 0 for not present Blockage of Nasal Breathing
Eye Pain / Pressure
Throat Pain / Pressure
Runny Nose
Ear Pain / Pressure
Frequent Throat Clearing
Chronic Cough
Itchy Eyes
Bad Breath
Postnasal Drainage
Watery Eyes
Facial Pain / Pressure
Scratchy Throat
Head Pain / Pressure
Teeth Pain / Aching
Puffy Eyes
General Fatigue
What single problem with your nose and sinuses bothers you most? _______________________________________________________________________________ _______________________________________________________________________________ 4004 Dupont Circle, Suite 220 Louisvil e, Kentucky 40207


Flexible Spending Accounts: What’s Eligible? The IRS defines eligible health care expenses as amounts paid for the diagnosis, cure, mitigation or treatment of a disease, and for treatments affecting any part or function of the body. The expenses must be primarily to alleviate a physical or mental condition or illness. This list is not meant to be all-inclusive. Eligible Expenses DE

Bvba dr

Onderzoek Nederland: ook e-sigaret is giftig en gevaarlijk AMSTERDAM 28/11 - De elektronische sigaret is, net als een gewone peuk, een verslavend product dat zeer giftige stoffen bevat. Dat blijkt uit nieuw onderzoek van het Nederlandse Rijksinstituut voor Gezondheid en Milieu (RIVM), zo schrijft het Algemeen Dagblad donderdag. De Nederlandse overheidswaakhond op het gebied van vo

Copyright © 2014 Medical Pdf Articles