Please answer all questions:
* Required Fields.

*Patient Name:


*Mailing Address:


*City:


*State/Zip:
/

*Area Code and Phone Number:


*Date of Birth:
(MM/DD/YYYY)


Date:
(MM/DD/YYYY)


* Email Address:

Which Doctor are you interested in seeing?
Choose one... Dr. Gunter Dr. Cochran

1. How did you hear about us?


2. Did another doctor refer you to us? If so, please list name.


3. How did you find our website?
Choose one... Search Engine Advertisement A friend Unknown

* 4. What is your reason for seeing the doctor?


* 5. List in priority the things that bother you about your nose and what you would like corrected.


6. If you have nasal breathing problems:
(If not, go to question #7)
** Please answer (n/a) if not applicable.

a. Is your breathing problem primarily on one side or both?


b. When does it bother you most?
(season, time of day, with exercise, etc.)


c. What can you do to improve your breathing?


d. Please estimate the percentage you feel your breathing is decreased in each nostril.
(Example: 100%= completely blocked, 50%= getting half the air you think you should, etc.)

Left   %
Right %

7. Have you had any previous nasal surgery? (If no, go to question #10)
** Please answer (n/a) if not applicable.


If yes, how many?


a. Was it to improve breathing, the appearance or both?


b. When was your last surgery performed?


c. Who did your surgeries? (name of doctor and specialty)


8. Do you know if any cartilage from inside your nose (the nasal septum) has been removed to correct a deviated septum or used as a graft to improve the shape of your nose?


9. Has any cartilage or bone from other parts of your body (ribs, ears, skull, etc.) or any implants (artificial grafts) been used in your nose (Be specific)?


* 10. Are you expecting insurance to pay for any part of your surgery? (They usually will pay only if you have significant nasal breathing problems or a traumatic deformity documented by x-ray, or verified by an emergency room visit.)


If you are, what is the name of your insurance company?


11. If you have surgery, what are your realistic desires, i.e., what will/would it take for you to be satisfied with the outcome? Think about this and be honest.




Medical History:
Do you or have you ever had any of the following?


Rheumatic Fever

Yes          No

Heart Trouble

Yes          No

Heart Murmurs

Yes          No

Heart Palpitations

Yes          No

Irregular Heart Beat

Yes          No

Chest Pains

Yes          No

Shortness of Breath

Yes          No

Swelling of Ankles

Yes          No

High Blood Pressure

Yes          No

Herpes "Fever Blister"

Yes          No

Chronic Lung Problems

Yes          No

Diabetes

Yes          No

Cancer

Yes          No

Kidney Problems

Yes          No

Eye Diseases

Yes          No

Hepatitis

Yes          No

Thyroid Problem

Yes          No

Asthma

Yes          No

Anemia

Yes          No

Blood Disorders

Yes          No

Skin Disorders

Yes          No

Trouble with dryness, soreness, burning, itching, or excessive tearing of eyes


Yes          No

Any other serious illness

Yes          No

Have you ever had MRSA (Methicillin-resistant Staphylococcus aureus):

13. Hospitalizations and/or previous surgery:

Please list with dates:


14. Allergies: Are you allergic to or have you ever had a reaction to any medication, drug or local anesthetic? Please list:


15. Medications: Are you now or have you ever taken any medications on a regular basis (aspirin, birth control pills, vitamins included)? Please list:


16. Are you now or have you ever taken a prescription or over the counter medication for allergies, stuffiness, difficulty breathing, sinuses or other nasal problems? Please list:


Bleeding/Scarring/Anesthesia:

Do you or any member of your family have difficulty with prolonged bleeding when cut?
Yes         No

Do you or a member of your family bruise easily?
Yes         No

Do you have a problem with excessive scarring or have you ever formed a keloid after being cut?
Yes         No

Have you or any member of your family ever had a problem with anesthesia?
Yes         No

Personal History:

Is your general health good?
Yes         No

Have you ever had psychiatric problems, a nervous breakdown or been under the care of a psychiatrist?**
Yes         No

**If "Yes," please explain:


*Do you smoke?
Yes         No

Previous cocaine use?**
Yes         No

**If you have a history of cocaine use, you must provide clearance from an ENT doctor stating you have no septal perforation, infection or damage to the internal lining of your nose.

17. Date of last physical examination:
(MM/DD/YYYY)


18. Do any diseases run in your family?

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