ENT CONSULTATION FORM
Patient Name [PatientName]
File Number [PatientID]
Nationality [Nationality]
DOB [DOB] / [Age]
Sex [Sex]
Insurance Provider [InsuranceProvider]

I. C/O

[ChiefComplaints]

II. HISTORY

2a. History of Present illness

[HistoryOfComplaints]

2b. Past medical and surgical history

[PastMedicalAndSurgicalHistory]

2c. Family History (including: social/psychological factors)

[FamilyHistory]

2d. Allergies/Adverse reactions (Food, Medication and others)

[Allergies]

III EXAMINATION

[Vitals]


3a. General
[GeneralExam]

3b. Local

3b.1. Ears:

[EarsExam]

3b.2. Nose and Sinuses:

[NoseAndSinusesExam]

3b.3. Throat and Larynx:

[ThroatAndLarynxExam]

3b.4. Head and Neck

[HeadAndNeckExam]

V DIAGNOSIS

[Diagnosis]

VI MANAGEMENT PLAN / INVESTIGATIONS

[Investigations]
 
 
Printed Date : [PrintDate]   Signature & Stamp
Dr. [DoctorName]
 [DocQualification] , [Speciality]
      GPH/MED/F029, Rev. 1