CENTA - Appointment Request

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Medical History Online Form

The form below is for patients who wish to submit their information online, electronically as an alternative to the traditional printed paperwork method.

Please complete the form in its entirety and then click the Submit Form button at the bottom to transmit your data to our offices.

Patient Information First Name: Last Name: DOB:
Referring Physician: Phone:
Other Specialists: Phone:

Describe why your child is here to see the otolaryngologist:

List any complications the patient experienced during pregnancy or birth:

If the patient was kept at the hospital more than two days after delivery, explain:

Birth Weight: Birth Hospital:

Health Information

Please check all problems/difficulties that apply to the patient:

Ear InfectionsStomach Or Digestive
Sinus InfectionsKidney Or Bladder
Throat InfectionsNeurological/Seizure
Sleep Apnea Or Disturbed BreathingThyroid/Blood Sugar
Heart Or CardiacDelays In Development
Breathing Or LungHearing
Any concerns regarding patient speech development?

If the patient was ever hospitalized, list reasons and dates:

List any patient surgeries, dates, and surgeon names:

Patient circumcised?

Medication Information Name: Dosage: How often?
Doctor:

Name: Dosage: How often?
Doctor:

Name: Dosage: How often?
Doctor:

List all drug allergies (if any):

List all environmental allergies (if any):

General Patient Information In daycare? Bottle use? Pacifier use?
If in school, what school and grade?

If a family history of hearing loss exists, list relationship to patient and age?

List any other pertinent information you would like to provide to the specialist:

By submitting this information online, I acknowledge that I have read, understand and accept the notice of privacy practices.

Children's Ear Nose & Throat Associates
Phone: 407.253.1000 • Metrowest Fax: 407.253.1010 • Maitland Fax: 321.397.0000