New Patient Forms

Before you first visit, please read, fill out, and e-sign the following documents. This helps speed up the insurance verification and registration process, making your wait time a lot shorter.

Personal Health History Form

General Questions








InternetDoctor ReferralFacebook/Twitter/Social MediaInsurance ListSeen on TVRead in MagazineSeen Dr. Pasha at a LectureDrove By/Saw SignReferred by a FriendReferred by a PatientRadio Ad

Past Medical History


AlcoholismAnemiaAnxiety/Panic AttacksArthritisAsthmaBleeding DisorderDepressionDiabetesDrug (Chemical) DependencyEmphysema or COPDEpilepsy (seizure)Gastroesophageal Reflux/Peptic Ulcer DiseaseGoiterHeart Disease (Prior Heart Attack, Heart Failure, Angina)Hepatitis or Liver DiseaseHigh Blood Pressure (Hypertension)High cholesterolHIV/AIDSHyperthyroidism (High Thyroid)Hypothyroidism (Low Thyroid)Immune DeficiencyKidney DiseaseLung DiseaseMigrainesMultiple SclerosisPneumonia/BronchitisPsychiatric CareRheumatic FeverScarlet FeverSleep ApneaStroke or Transient Ischemic Attacks (TIAs)SyphilisTuberculosis

YesNo


YesNo


YesNo

Past Surgical History


Tonsillectomy/AdenoidectomySeptoplasty/Turbinate ReductionOffice Procedure for Nasal ObstructionSinus SurgeryRhinoplastyUP3/Sleep Apnea SurgeryOffice Procedure for Snoring/Sleep ApneaEar TubesOther Ear SurgeryThyroidectomy

YesNo

Medications


YesNo

YesNo

YesNo

Social History


YesNo



YesNo



YesNo


Family History

Head and Neck CancerSleep ApneaThyroid DiseaseProblems with AnesthesiaHearing LossAllergies

YesNo


Medical Questionnaires

Sleep apnea and rhinosinusitis are two conditions that many Americans suffer from and often, may not even realize it. When left untreated, these conditions can lead to other serious physical and mental health issues. If you think you may be suffering from sleep apnea or rhinosinusitis, fill out one or more of the questionnaires below, and Dr. Matorin and his staff will go over the results with you at your appointment. From there, they will work with you to find a customized treatment plan suited for your needs.

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