3838 California Street, Suite 505, San Francisco, CA 94118Telephone 415.751.4914 Fax 415.751.1414 www.sfent.com· ·

San Francisco Ear Nose & Throat Medical Group, IncSFSFENTENT

Thomas L. Engel, M.D.

Vanessa R. Erickson, M.D.

Daniel F. Hartman, M.D.

Aditi H. Mandpe, M.D.

Robert A. Mickel, M.D., Ph.D.

Scott D. StonePractice Administrator

Adult & Pediatric Otolaryngology Hearing Disorders Endoscopic Sinus Surgery Head & Neck Surgery· · ·

Dear New Patient,

Hello and welcome to our practice!

The San Francisco Ear, Nose and Throat Medical Group is a group of five Otolaryngologist/Head and Neck Surgeons or ENT doctors, as they are often called. We strive to exceed your expectations for high-quality and timely care. As a group, we have expertise in most areas of this specialty. We care for a wide variety of problems in adults and children including hearing loss, ear infection, balance disorders, nasal deformity, nasal and sinus diseases, throat disorders, voice disorders, snoring and sleep apnea, thyroid and parathyroid disorders and head and neck cancer. One of our physicians also distributes hearing aids.

Our office is located in Suite 505 at 3838 California Street next to the California Campus of the California Pacific Medical Center. We are located on the north side of the street between Cherry and Arguello Streets.

Please print the included three page patient registration and health information form and bring the completed form to your first visit. For your first visit, please plan on arriving 15 minutes prior to your appointment to complete your registration. Please also bring insurance information and referral information if it is required by your insurance company/medical group.

Our doctors are providers for many Health Maintenance Organizations (HMOs) through the Brown and Toland Medical Group. We also contract with many preferred provider organizations (PPOs.) Please confirm that we are contracted providers with your insurance company as our patients have the final financial responsibility for the services that we provide.

We will be pleased to see you even if we are not participating providers with your insurance company. If this is the case, your insurance company is likely to pay some of the cost of your visit. If we are not a participating provider with your insurance company, payment is expected at the time of your visit and we will courtesy bill your insurance company to help you collect the balance due from them.

We look forward to meeting you and are delighted that you have chosen to come to our office. We welcome any comments that you may have.

Sincerely,

Scott StonePractice Administrator

PATIENT NAME: DATE OF BIRTH: DATE: MEDICAL HISTORY: Do you have or have you ever had any of the following medical problems? If yes, please check the box next to the problem. □ Anemia □ Asthma □ Emphysema □ Pneumonia/Bronchitis □ Bleeding/Blood disorder □ Cancer (type________) □ Diabetes □ Thyroid Disease

□ Epilepsy/Seizures □ Stroke □ High blood pressure □ Heart problems □ Stomach ulcer/Acid reflux □ Liver disease □ Hepatitis □ High cholesterol or lipids

□ Kidney disease □ Tuberculosis □ HIV/AIDS □ Other Immune disorder □ Arthritis □ Depression □ Glaucoma □ Other____________

Please list all surgeries: 1.________________________________________________ Date_____________________ 2.________________________________________________ Date_____________________ 3.________________________________________________ Date_____________________ Have you ever had problems with anesthesia? □ NO □ YES Explain:____________________ Please list all Hospitalizations and serious illnesses: 1._________________________________________________ Date____________________ 2._________________________________________________ Date____________________ 3._________________________________________________ Date____________________ MEDICATIONS: If you don’t take any medications, check this box: □ Prescription medications Name, Dosage & Directions ____________________________________________________________________ ____________________________________________________________________

Name, Dosage & Directions ____________________________________________________________________ ____________________________________________________________________

Over the counter medications: (Aspirin, Ibuprofen, Naproxen)__________________________ Herbs, Natural medications Name, Dosage & Directions ____________________________________________________________________

Name, Dosage & Directions ____________________________________________________________________

MEDICATION ALLERGIES: If you don’t have any allergies to medications, check this box: □ Medication & Reaction ____________________________________________________________________

Medication & Reaction ____________________________________________________________________

FAMILY HISTORY: Do you have a family history of major medical problems? If yes, check the box below: □ Cancer (type______________________) □ Diabetes _________________________ □ Heart disease______________________

□ Allergies__________________________ □ Unexpected, early hearing loss________ □ Other____________________________

Revised March 2010

PATIENT NAME: DATE OF BIRTH: DATE: SOCIAL HISTORY: Do you or did you drink alcohol? □ NO □ YES Amount of drinks a day?______________

If you quit, when?____________________ Do you or did you use tobacco? □ NO □ YES Cigarettes: packs per day_____ How many years_____ If quit, when? _________ Other tobacco: type______amount a day_____ if quit, when?___________________ Do you or did you use recreational drugs? □ NO □ YES REVIEW OF SYSTEMS Place a check next to any illness, symptoms or problems you have had in the past month: CONSTITUTIONAL SYMPTOMS □ Good general health □ Recent weight change □ Loss of appetite □ Fatigue □ Fever/sweats

EYES □ Eye disease or injury □ Eye glasses or contact lenses □ Blurred or double vision □ Glaucoma

EARS/NOSE/MOUTH/THROAT □ Hearing loss □ Hearing noises in your ear □ Earaches or drainage □ Nosebleeds □ Trouble swallowing □ Bleeding gums □ Sore throat □ Snoring □ Voice changes

MUSCULOSKELETAL □ Joint pain/ stiffness □ Muscle pain/ cramps/ weakness □ Back pain

CARDIOVASCULAR □ Chest pain/ angina □ Palpitations □ Shortness of breath □ Swelling of feet, ankles, or hands □ Murmur

RESPIRATORY □ Cough □ Spitting up blood □ Shortness of breath □ Wheezing

GASTROINTESTINAL □ Problems with bowel movements □ Nausea or vomiting □ Rectal bleeding or blood in stool □ Abdominal pain or heartburn

GENITOURINARY □ Flank pain □ Problems with urination □ Blood in urine □ Kidney stone

NEUROLOGICAL □ Headaches □ Numbness or tingling sensations □ Tremors □ Head injury

HEMATOLOGIC/LYMPHATIC □ Slow to heal after cuts □ Bleeding or bruising tendency □ Phlebitis or blood clots □ Past blood transfusion

OTHER SYMPTOMS □ Memory loss or confusion □ Nervousness □ Depression □ Insomnia

Current Height:___________________ Current Weight:_____________________ Completed by:____________________Relationship__________________ Date___________ Reviewed by Clinician:__________________________________________ Date___________

Revised March 2010