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Get Skylands Medical Group Otolaryngology New Patient Questionnaire

History: Heart Disease Angina Diabetes Stroke Heart Attack Peptic Ulcer Date Asthma Arthritis ) Other Problems: Surgical History: Allergies: Medications: Immunization Status: Tobacco Use: Alcohol Use: Drug Use: Review of Systems: Fever Weight Loss Chills Loss Of Appetite Blurred Vision Double Vision Decreased Vision Hearing Loss Ear Infections Noises In Ear Dizziness/Vertigo Abnormal Taste Chronic Cough Wheezing Difficulty Swallowing Abnormal Smell Shortness of Breath Nause.

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