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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