We appreciate the opportunity to serve you and we know that your time is valuable.  Our
practice uses a state-of-the-art electronic medical record to better serve you.  To expedite
your visit and reduce your wait time, please take a few moments to complete the
preregistration form below.  You may use the tab key to navigate through the form.  Press the
"send" key when finished to deliver your form to our office for processing.
Person Responsible For Payment (If different from patient)
Family History:  Please check all conditions present in your family.
Review of Systems (Please check all conditions you currently have or have experienced in the past)
This is a secured site for your protection.  All information entered will be used solely for the purpose of patient processing within our office.
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Services
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Copyright © 2005 ENT and Voice Care of Atlanta Inc. All rights reserved.
contact@entandvoicecare.com


Patient Registration
Patient Information
Primary Insurance Information
Secondary Insurance Information
Medical History Worksheet
Hearing Loss
Ear disease
Problems with Anesthesia
Bleeding
disorders
Social History:
Tobacco use:
Never
Current
Previous
Alcohol consumption:
Never
Minimal
Moderate
Heavy
If patient is a child:
Attends day care
Exposed to second hand smoke
General:
Unexplained
weight loss
Weight gain
Unexplained
fever
Night sweats
Persistent
cough
Skin:
Acne
Psoriasis
Eczema
Eyes:
Glaucoma
Cataracts
Macular degeneration
Double
vision
Wear
glasses
Wear contacts
Heart:
High blood
pressure
Chest pain
Angina
Congestive
heart failure
Murmur
High
cholesterol
Heart attack
Circulatory
problems
Irregular
heartbeat
Lungs:
Asthma
Pneumonia
Snoring
Sleep apnea
Bronchitis
Exposure to
TB
Gastrointestinal:
Heartburn
Acid reflux
Ulcers
Colon
problems
Crohn's
disease
Diverticulitis
Hepatitis
Genitourinary:
Kidney
problems
Bladder
problems
Prostate
problems
Pregnancy
(women only)
Arthritis
Gout
Fibromyalgia
Musculoskeletal:
Neurological:
Seizures
Epilepsy
Migraines
Head injury
Stroke
Mini-strokes
Psychiatric:
Depression
Anxiety
Panic attacks
Cancer History:
Hematologic /
Lymphatic:
Anemia
Bleeding
disorder
Lymphoma
Leukemia
Thyroid
problems
Pituitary
disorder
Diabetes
Endocrine: