ENT (Ear, Nose & Throat) Intake Form

The ENT Intake Form is specifically designed for otolaryngology practices, capturing the detailed head and neck symptom history that ENT specialists need for accurate diagnosis and treatment planning. This template collects patient demographics alongside a structured assessment of ear symptoms (hearing loss, tinnitus, otalgia, otorrhea, vertigo), nasal and sinus symptoms (congestion, rhinorrhea, post-nasal drip, anosmia, facial pressure, epistaxis), and throat symptoms (hoarseness, dysphagia, globus sensation, sore throat, snoring, sleep-disordered breathing). Each symptom domain includes onset, duration, laterality, and severity scales.

Built for general otolaryngology, rhinology, otology, laryngology, and head and neck surgery practices, this form includes sections for prior ENT procedures (tonsillectomy, septoplasty, sinus surgery, tympanoplasty, thyroidectomy), hearing test history, allergy testing results, CT and MRI imaging history, and a comprehensive medication list covering nasal sprays, antihistamines, decongestants, and antibiotics. The voice and swallowing section captures occupational voice demands and dietary modifications.

All fields are HIPAA-compliant and structured to streamline the ENT consultation workflow. Patients systematically document their head and neck symptoms before the visit, enabling the provider to focus the physical examination and determine whether additional diagnostic testing such as audiometry, nasal endoscopy, or imaging is warranted. The organized format ensures no symptom domain is overlooked during the initial evaluation.