Bechara Y. Ghorayeb, MD www.houstonoto.com
OTOLARYNGOLOGY - HEAD AND NECK SURGERY 
1140 Business Center Drive, Suite 560, Houston, Texas 77043 Tel: (713) 464 2614 Fax: (713) 464 0729
PATIENT NAME:_____________________________________________________ DATE :_______/________/________
DOB:______/______/_____________ WHO REFERRED YOU?_____________________________________________
CHIEF COMPLAINT
PAST HISTORY
Have you ever had any of the following surgeries?
Please describe why you are seeing the doctor today_______________________________________________________
How long have you had this problem? ______________days____________months__________years__________
Have you ever had any of the following? (please check all that apply)
_________________________________
SOCIAL HISTORY
Do you smoke?
If yes, how many cigarettes per day?_______
If no, when did you quit?_________________
Do you drink alcohol?
Have you had or do you have a problem with drugs?
Occupation________________________ Have you been exposed to loud noise?
CURRENT MEDICATIONS
Name of medication
Dose
Reason for taking
ALLERGY TO MEDICATIONS:_________________TO:______________________________________________________
ALLERGY TO LATEX
The above information is to the best of my knowledge.
Patient's signature:_______________________________Date: ______/______/____________
TODAY, DO YOU HAVE ANY OF THESE SYMPTOMS?
EARS:
NOSE:
THROAT:
LARYNX:
NECK:
NEURO:
SKIN:
THYROID:
PARATHYROID:
FAMILY HISTORY
(type______________)
__________________________________________________________________________________________________
PLEASE FILL OUT THE BACK OF THIS FORM
