Please answer all questions:
All questions must be answered before the form can be submitted.
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...
Docshop.com
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.
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.
12. If you desire, you can send photographs from magazines of the type of nose you prefer - to give us some idea of what you are hoping for.
Medical History
:
Do you or have you ever had any of the following?
Rheumatic Fever
Heart Trouble
Heart Murmurs
Heart Palpitations
Irregular Heart Beat
Chest Pains
Shortness of Breath
Swelling of Ankles
High Blood Pressure
Herpes "Fever Blister"
Chronic Lung Problems
Diabetes
Cancer
Kidney Problems
Eye Diseases
Hepatitis
Thyroid Problem
Asthma
Anemia
Blood Disorders
Skin Disorders
Trouble with dryness, soreness, burning, itching, or excessive tearing of eyes
Any other serious illness
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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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