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CC & HPI
|
|
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Hearing
• • •
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Nasal Congestion
• • •
|
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PND
• • •
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Bruxism
• • •
|
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GERD
• • •
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Cough
• • •
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Stuffy Ears
• • •
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Dysphagia
• • •
|
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Tinnitus
• • •
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Vertigo
• • •
|
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Dizziness
• • •
|
Mouth Breather
• • •
|
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Throat Congestion / Clearing
• • •
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Insomnia / Sleep Disorder
• • •
|
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Custom CC/HPI
|
|
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Patient Allergies
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PAST MEDICAL / SURGICAL Hx:
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COPD
|
|
HTN
|
Embolism
|
|
Pneumonia
|
Respiratory Failure
|
|
Effusion
|
Anemia
|
|
Diabetes
|
Asthma
|
|
Aphasia
|
Low Thyroid
|
|
Dementia
|
Rhinoplasty
|
|
Multiple Sclerosis
|
Tracheotomy
|
|
Sinus Surgery
|
Tonsillectomy and/or Adenoidectomy
|
|
Ventilator Dependent
|
Ear
• • •
|
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MRSA
• • •
|
Other
|
|
Cancer
|
|
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Previous Audiogram (Date & Finding)
|
|
|
|
|
|
PHYSICAL EXAM
|
|
|
EARS
|
|
|
TM's
• • •
|
Canals
• • •
|
|
Weber
• • •
|
Rinne
• • •
|
|
|
|
|
NOSE
|
|
|
Septum
• • •
|
Turbinates
• • •
|
|
Anterior Rhinoscopy
• • •
|
|
|
|
|
|
NECK
|
|
|
Neck
• • •
|
Thyroid
• • •
|
|
Carotids
• • •
|
Adenopathy
• • •
|
|
OTHER:
|
|
|
|
|
|
THROAT
|
|
|
Tonsils
• • •
|
Mouth
• • •
|
|
Tongue
• • •
|
Palate
• • •
|
|
OTHER:
|
|
|
|
|
|
ENDOSCOPY:
|
|
|
Diagnostic Nasal Endoscopy
|
Septum
• • •
|
|
L Inf. Turb
• • •
|
R Inf. Turb
• • •
|
|
L Mid Turb
• • •
|
R Mid Turb
• • •
|
|
External Nose
• • •
|
|
|
% Occlusion - Left
• • •
|
% Occlusion - Right
• • •
|
|
Nasopharynx
• • •
|
Nasopharynx - Abnormal Description
|
|
Eustachian Tubes
• • •
|
Eustachian Tubes - Abnormal Description
|
|
|
|
|
Diagnostic Laryngoscopy
|
|
|
R Vocal Cord
• • •
|
L Vocal Cord
• • •
|
|
Epiglottis
• • •
|
GERD
• • •
|
|
Other
|
Other Pertinent Findings
|
|
|
|
|
DIAGNOSIS
• • •
|
DIAGOSIS - OTHER
|
|
|
|
|
PLAN OF TREATMENT
|
|
|
Medication Prescribed
• • •
|
Audiogram?
• • •
|
|
Follow-up
• • •
|
Unable to Examine Patient Because...
• • •
|
|
Procedures Performed
• • •
|
|
|
Electronically Signed by
|
|
