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


Welcome to Our Office (Pediatrics - 17 & under)
 
 Date of Birth:
 
 

 Did a Physician refer you?

 
 

 If referral is other than a Physician, please indicate:

 

 

General Medical Information
 
 
 

 
 

Are immunizations up to date?

Does child bruise easily?

Has child ever had cut such that bleeding was difficult to control?


Personal Medical History
 
       
       
       
       
 


Family History
 
       
       
       


Surgical History
 
    Do you have any objection to the use of blood products? (in the unlikely event they should become necessary)
     
Has your child or any family member had a reaction to any local or general anesthetic?
 
 


Allergies
 
Does your child have any allergies to medication?
 

 
Allergic to Latex?
 
Allergic to X-Ray Dye?
 
 
 
Medications
    Does your child take any medications on a regular basis?
    
 
    
 
 
 Parent's Signature (please sign with mouse):

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Today's Date: