MARC J. KAYEM, M.D., F.R.C.S.C.
MICHELLE A. PUTNAM, M.D.

OTORHINOLARYNGOLOGY
FACIAL COSMETIC SURGERY
HEAD AND NECK SURGERY
LIPOSUCTION SURGERY

3831 Hughes Ave., Suite 504, Culver City, CA 90232 - Tel.: (310) 204-4111 - Fax: (310) 204-4474 - Email: marcmd@drkayem.com - www.drkayem.com
Sierra Park Clinics, 85 Sierra Park Rd/PO Box 660, Mammoth Lakes, CA 93546 - Tel.: (800) 200-face (3226) - FAX (760) 924-4034

Name: 		Date of Birth:
Please Summarize the Reason for Your Visit:

Please Check any of the Following that Apply to You:
  Ear Problems   Throat / Nasal Problems   Other Problems
Hearing Problems Swallowing Problems Lumps in the Neck
Ear Pain or Pressure Frequent Sore Throat Frequent Colds
Ear Drainage Prolonged Hoarseness Heartburn / Indigestion
Ear Ringing / Noise Nasal Obstruction / Bleeding Snoring
Exposure to Loud Noises Sinus Infections Sleep Apnea
Hearing Aids Allergy Problems Cough
Dizziness / Loss of Balance Facial Pain / Headaches Wheezing
Past Ear, Nose and Throat Operations: Bleeding Problems
Please Check if You have any of the Following Medical Problems:
High Blood Pressure Ulcers Diabetes
Previous Heart Attack Family History of Bleeding
Problems		 Tuberculosis
History of Chest Pain   Previous Cancer
History of Heart Disease Asthma / Emphysema    
List any other Medical Problems, Previous Hospitalizations or Previous Surgeries:

Are you Allergic to any Medications? No Yes    
How Many Drinks of Alcohol Do You Have Daily? None Number:

Or per Week?
Do You Smoke Now?

No

Yes

Packs per Day?

For How Many Years?

Years:

    
Did You Use to Smoke? No Yes

Packs per Day?

When did You Stop?

 Year:    
Do You Take ANY Medications? No Yes    
Please List All Medications You are Currently Taking, Including Over-the Counter and Homeopatic Medications:
1. 2. 3.
4. 5. 6.
Check Here if You Take More Than 6 Medications and Continue List on Reverse Side of This Page.
I HEREBY CONSENT TO ANY EXAMINATION, LABORATORY TESTS, ANESTHESIA, MEDICAL OR SURGICAL TREATMENT, OR CLINICAL SERVICES DEEMED MEDICALLY NECESSARY BY MY PHYSICIAN.

Patient Signature:		  
Date: