Michigan Otolaryngology
Center for Ear, Nose & Throat Health (ENT)
J. Martin Ulrich, D.O., F.O.C.O.O.


Welcome to Our Office
 
 Date of Birth:
 

 Did a Physician refer you?

 
 

 If referral is other than a Physician, please indicate:

 

 


 

General Medical Information
 
 
 

 
 


Social History
 
Marital Status: 
 
​​​Use of Alcohol: 
 
Do you smoke?
 
 
Chewing tobacco:
 
Use of Drugs:
 
Excessive exposure at home or work to (check all that apply):
 


Allergies
 
Do you have any allergies to medication?
 

Allergic to Latex?
 
Allergic to X-Ray Dye?
 
 
 
Medications
 


Medical History
 
 Metabolic:
  Diabetes    
  Blood Clots    
  Bleeding Problems    
  Anemia    
  Thyroid Disorders  
 Infectious Diseases:
  A.I.D.S. - H.I.V.
  Hepatitis (Jaundice)
  Infectious Mono
  Meningitis
​​​​​ Gastrointestinal / Renal:
  Ulcers    
  Vomiting    
  Abdominal Pain    
  Kidney Disease    

Heart Problems:
  Myocardial Infarction (Heart Attack)    
  Angina (Chest Pain)    
  Arrhythmia (Skipped Beats)    
  Heart Murmur    
  Mitral Valve Prolapse    
  High Blood Pressure (Hypertension)    

Neurologic:
  Alterations in Vision (Glaucoma)    
  Seizures / Convulsions    
  Strokes / C.V.A.    
 
 Lung Problems:
  Emphysema / COPD    
  Tuberculosis (T.B.)    
  Asthma    
  Shortness of Breath    
  Snoring/Sleep Apnea    
  Seasonal Allergies    
 
Cancers / Tumors: (please describe)


Surgical History
 
 Have you or any family member had a reaction to any local or general anesthetic?
 


Family History
       
       
 
  Other History

Hospitalizations
 
 
 
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Today's Date: