Clermont Medical Center
What medications are you taking now?
List all vitamins and other supplements that you are taking
Are you allergic to any medications? No Yes If yes, please list and reaction.
Past Medical History and Current History:
CancerDiabetesHeart Attack / AnginaHeart FailureStrokeHigh blood fat (Cholesterol / Triglycerides)High blood pressure (Hypertension)Sleep ApneaThyroid DiseaseOther (describe): For Men Only:
When was your last: (Please list the date)Physical For Women Only:
When was your last: (Please list the date)Physical Flu Shot Have you ever been pregnant? No Yes If yes:Number of miscarriages Have you ever used birth control pills No Yes If yes, when: Are you in menopause If yes, age at last period: Do you take: Estrogren? How long have you been on hormone replacement therapy (if applicable)? Surgery History:

AppendectomyDental SurgeryGallbladderHerniaHysterectomyTonsillectomyOther (describe): Hospitalizations: Please list only overnight hospitalizations other than surgery or child birth.
Family History:
Have you ever used tobacco? No Yes Year quit:
If yes, every day?
How soon after you wake up do you smoke your first cigarette? Tobacco used other than smoking? No Yes ❖ Did you have a drink containing alcohol in the past year? No Yes
If yes, how often:
How many drinks did you have on a typical day when you were drinking in the past year? How often did you have 6 or more drinks on one occasion in the past year? Are you feeling down, depressed or hopeless? No YesDo you feel little interest or pleasure in doing things? No YesHave you ever used recreational drugs? No Yes When? How much caffeine daily? REVIEW OF SYMPTOMS: (please indicate if you have any of the following)
Please comment on any other information you feel the doctor should know or discuss with you.
The onset of hearing loss is usually very gradual. It may take place over 25-30 years or it may happen more rapidly if you are exposed to loud noises at work or through hobbies. Because it usually occurs slowly, you may not even be aware you have a problem until someone else brings it to your attention. Here is a simple test you can take to determine if you have a hearing problem.
1. Do others complain that you watch television with the volume too high? 2. Do you frequently have to ask others to repeat themselves? 3. Do you have difficulty understanding when in groups or in noisy 4. Do you have to sit up front in meetings or in church in order to 5. Do you have difficulty understanding women or young children? 6. Do you have trouble knowing where sounds are coming from? 7. Are you unable to understand when someone talks to you from another 8. Have others told you that you don’t seem to hear them? 9. Do you avoid family meetings or social situations because you “can’t 10. Do you have ringing or other noises (tinnitus) in your ears? Patient Consent to the Use and Disclosure of Health Information
for Treatment, Payment, or Health Care Operations
As part of your health care, this practice originates and maintains paper and/or electronic records describing your health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. This • A basis for planning your care and treatment• A means to communicate with health professionals who contribute to your care• A source for applying your diagnosis and treatment information for payment purposes As part of your treatment, payment, or health care operations, it may become necessary to disclose health information to other health care providers (referrals or consultation), laboratories, insurance companies for payment and/or other individuals or agencies as permitted or required by state or federal law.
I have been provided with a copy and the opportunity to read the “Patient Health Information Privacy Practices” that provides a more complete description of health information uses and disclosures. I understand that I have the following • The right to read “Patient Health Information Privacy Practices” prior to signing this consent• The right to request a copy of the “Patient Health Information Privacy Practices” for my own use• The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.
I request the following restrictions to the use or disclosure of my health information: I fully understand, acknowledge and accept this consent.
*If other than patient is signing, are you the parent, legal guardian, custodian or have Power of Attorney for this patient, for treatment, payment or health care operations? Yes [ ] No [ ] FOR OFFICE USE ONLY
[ ] “Counsel form” reviewed by (employee)
[ ] Patient refused to sign consent form.
[ ] Reason for patient refusal to sign [ ] Restrictions were added by the patient (see restrictions listed above)


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