anwar mumtaz, md

We listen & care for our patients

HISTORY FORM .  please  right click and select the form below and then print the selection. 




Patient’s Name ________________________________AGE _____    Date of Birth _______ sex _____                                            

Chief complaint and Symptoms          Please write any symptoms and complaints you have and the reasons you come to visit us:

EAR    ------------------------------------------------------------------------------------------------------------- ------------------------------------------------

NOSE --------------------------------------------------------------------------------------------------------------------------------------------------------


HEAD AND NECK -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

 Duration of symptoms PLEASE give as much information as possible about your symptoms and complanits


REVIEW OF SYSTEMS          PLEASE list any of the symptoms you have now   and HOW LONG -----------------------------------------------------

    Significant weight change?   Loss or Gain?           How much     fever/chills        

     Any eye problems?              Glaucoma/ double vision       blindness      cataract    eye itching ,blurry vision     

     ANY EAR PROBLEM :           pain                           hearing loss     pressure           difficulty equalizing ears

      Noise and ringing/tinnitus             drainage                dizziness /vertigo              nausea/ vomiting,       

       jaw joint problem/TMJ                 Bell’s palsy              

 Any NOSE OR SINUS  problem?      Nasal obstruction      headache         migraine headache/ Facial pain    teeth pain 

                                    pressure                  drainage/  post nasal drip                    Runny nose                

     smell problem         malodor                                 Bad taste from drainage                   persistent cough       

     Purulent or yellow drainage                     Any nose bleeds?          Any recent teeth extraction   

     Snoring/sleep apnea         Daytime sleepiness       Driving difficulty due to sleepiness 


    ANY THROAT PROBLEMS        Trouble swallowing?       Any heart burn/reflux  

      Any burning sensation when eating or drinking                      Any hoarseness / loss of voice  /change in voice           

     Tonsil problem                   tonsil stones                              bad breath                  any phlegm in throat  

     Difficulty clearing your throat                                               Coughing up any blood      


     Chest pain or tightness             Any heart problem            Any shortness  of  breath  on exertion

      Swelling of legs and feet      any history of blood clots         Palpitation

      Atrial fibrillation                       any blood thinners                      Night sweats    

    EMPHYSEMA/COPD              asthma                 bronchitis         


     STROKE /TIA             Spells of weakness of arm or legs             

     Spells of dizziness?       Speech problem       Migarine headaches      passing out spells

    Depression/   anxiety/            Hallucination

    Enlarged or swollen glands   Any lumps in neck    cervical arthritis

    Skin irritation or rashes     eczema          psoriasis       

   any prostate problem          any thyroid problems             






          NAME-------------------------------------------------------- Date ---------------------------

 Social History    Occupation______________ SMOKING ? Yes      No    if yes how much  _____

Prior tobacco use:        Yes      No       How long, _______ When did you quit? ___________

Do you drink alcohol    ______________  how much_______________ did you ever drink heavy

How much caffeine or sodas do you drink;_________________  ANY DRUG USE,



Medical History (Circle where appropriate). Please write any medical problems you have had 

 EAR  problems :  hearing loss ,       ringing ,     pain ,        discharge,     any history of noise exposure ,     Any gun shootings,         

any history of trauma to the ears ,    any dizziness or vertigo,

Any Minier’s disease,       any balance disorder      STROKE , Parkinson’s disease        myasthenia gravis 


 THROAT problems  ,    sore throat,    trouble swallowing ,    hoarseness,  HEART BURN , reflux

Difficulty clearing throat,   phlegm,     taste problems ---dryness of mouth and throat,


 NOSE AND SINUS   problems            difficulty breathing ,      pain ,        pressure ,   

SINUS HEADACHES,        migraine headaches  ,      post nasal   drainage         smell problems  ,

foul odor or discharge ,        NOSE  bleeds,                 dryness and crusting  , any over the counter nasal spray use


Any cancer problem           Any blood thinners       Diabetes     diabetic neuropathy         High Blood Pressure              heart problem        chest pain             

 history of heart attack   Asthma           bronchitis/ copd               emphysema       Tuberculosis                 any blood in sputum           shortness of breath      

Liver Disease/ hepatitis/pancreatits         Bleeding Tendency        HIV  /syphilis                         arthritis              Kidney Disease/renal failure                   

Depression/Anxiety           Epilepsy/Seizures                  Mental Illness      weakness       numbness

Lyme disease/ mononucleosis      chronic fatigue syndrome             fibromyalgia       lupus      sarcoidosis


Previous Surgeries           ( List any surgeries even childhood surgeries )  

  tonsil or any throat surgery        any sinus surgery      nose surgery         ear surgery /mastoid surgery           

any open heart or lung surgery          cardiac stents    hernia       gall bladder     appendectomy 

             hysterectomy or prostate surgery               kidney or bladder surgery      

  any skin cancer surgery  or    any other cancer surgery          hip or knee replacement

CURRENT MEDICATION :              ______________           ________________     ______________

____________________                ______________            ________________      ______________

__________________                   ______________              ________________     ANY BLOOD THINNERS

 ANY DRUG ALLERGIES __________________________________________________      

Are you allergic to any foods or animals? If yes, please state what you are allergic to and your reaction?  ______________________________                Any  pet animals or birds -------------------


      FAMILY HISTORY   ;   diabetes      hypertension                  heart disease           dizziness                cancer          

                                                 hearing loss              allergies                     asthma /emphysema     

                                                sleep apnea                 mental illness / depression                 neurological problem              

            Myasthenia gravis /Parkinson disease            thyroid disease                                kidney /renal disease

            Sarcoidosis/ lupus/ eczema/ psoriasis               sarcoidosis.