ENT — New Patient Consultation Template

Consultation Information

Referring physician: [Name, specialty]
Reason for referral: [Chief complaint]
Date of consultation: [Date]
Urgency: Routine / Urgent

Chief Complaint

[Primary ENT concern]
Duration: [X] days/weeks/months/years
Laterality: Right / Left / Bilateral / N/A
Current status: Improving / Stable / Worsening / Fluctuating

History of Present Illness

For Ear Complaints

Hearing Loss:

Onset: Sudden / Gradual
Duration: [X]
Laterality: Right / Left / Bilateral
Severity: Mild / Moderate / Severe / Profound
Type suspected: Conductive / Sensorineural / Mixed
Fluctuation: Yes / No
Associated: Tinnitus / Vertigo / Aural fullness / Otorrhea

Tinnitus:

Laterality: Right / Left / Bilateral / Central
Character: Ringing / Buzzing / Pulsatile / Clicking / [Other]
Pitch: High / Low / Variable
Constant / Intermittent
Severity: [Impact on daily activities, sleep]
Aggravating: [Noise, quiet, position]
Associated: Hearing loss / Vertigo / TMJ symptoms

Vertigo/Dizziness:

Type: True vertigo (spinning) / Lightheadedness / Imbalance / Presyncope
Onset: Sudden / Gradual
Duration: Seconds / Minutes / Hours / Days / Constant
Triggers: Position change / Head movement / Spontaneous / [Other]
Associated: Nausea/vomiting / Hearing loss / Tinnitus / Aural fullness
Falls: Yes / No
Dix-Hallpike history: [If previously tested]

Ear Pain/Otorrhea:

Laterality: Right / Left / Bilateral
Pain character: Aching / Sharp / Pressure
Drainage: None / Clear / Purulent / Bloody
Odor: None / Foul
Duration: [X]
Prior ear infections: None / [Frequency]
Ear surgery history: None / [Procedures]

For Nasal/Sinus Complaints

Nasal Obstruction:

Laterality: Right / Left / Bilateral / Alternating
Duration: [X]
Constant / Intermittent
Worse: Daytime / Nighttime / Lying down / [Position]
Allergic symptoms: Yes / No — [Sneezing, itching, watery eyes]
Prior surgery: None / [Procedure, date]

Rhinorrhea:

Character: Clear / Purulent / Bloody
Anterior / Posterior (post-nasal drip)
Duration: [X]
Associated: Facial pain/pressure / Headache / Hyposmia

Sinusitis Symptoms:

Facial pain/pressure: Yes / No — Location: [X]
Purulent nasal discharge: Yes / No
Nasal obstruction: Yes / No
Hyposmia/anosmia: Yes / No
Duration: Acute (<4 wk) / Subacute (4-12 wk) / Chronic (>12 wk)
Prior CT sinus: [Date, findings]
Prior antibiotics: [List]
Prior sinus surgery: None / [Procedure, date]

Epistaxis:

Laterality: Right / Left / Bilateral
Frequency: [Episodes per week/month]
Duration of episodes: [Minutes]
Severity: Mild / Moderate / Severe (requiring ER/transfusion)
Anterior / Posterior / Unknown
Triggers: Nose picking / Dry air / Spontaneous / Trauma
Anticoagulation: Yes / No — [Drug]

For Throat Complaints

Sore Throat:

Duration: [X]
Severity: [X]/10
Dysphagia: None / Solids / Liquids / Both
Odynophagia: Yes / No
Associated: Fever / Neck swelling / Voice change / Otalgia
Recurrent: Yes / No — [Frequency of strep/tonsillitis]

Dysphagia:

Onset: Sudden / Gradual
Duration: [X]
Solids / Liquids / Both
Level: Oropharyngeal / Esophageal
Associated: Weight loss / Aspiration / Voice change / Regurgitation
Food impaction: Yes / No

Hoarseness/Voice Change:

Onset: Sudden / Gradual
Duration: [X]
Constant / Intermittent
Voice use: Professional (singer, teacher) / Heavy / Moderate / Light
Associated: Throat clearing / Cough / Reflux symptoms / Neck mass
Prior laryngoscopy: [Date, findings]

Globus:

Duration: [X]
Constant / Intermittent
Associated: GERD symptoms / Stress/anxiety / Dysphagia / Weight loss

For Head/Neck Mass

Location: [Anatomic site]
Duration: [X]
Size change: Stable / Growing / Fluctuating
Pain: Yes / No
Associated: Dysphagia / Voice change / Weight loss / Night sweats
Risk factors: Tobacco / Alcohol / Radiation / HPV
Prior biopsy: None / [Results]

ENT-Specific Review of Systems

[ ] Hearing loss [ ] Tinnitus [ ] Vertigo [ ] Ear pain [ ] Otorrhea
[ ] Nasal obstruction [ ] Rhinorrhea [ ] Epistaxis [ ] Facial pain [ ] Anosmia
[ ] Sore throat [ ] Dysphagia [ ] Odynophagia [ ] Hoarseness [ ] Globus
[ ] Neck mass [ ] Neck pain [ ] Snoring [ ] Apnea [ ] Daytime somnolence

Past Medical History

[Relevant conditions]
Allergic rhinitis: No / Yes — [Allergens, treatment]
Asthma: No / Yes — [Severity]
GERD: No / Yes — [Treatment]
Sleep apnea: No / Yes — [AHI, CPAP use]
Diabetes: No / Yes — [Type, control]
Immunocompromised: No / Yes — [Reason]
Autoimmune: No / Yes — [Type]

Surgical History

[Relevant surgeries, especially:]
Ear surgery: None / [Procedure, date, outcome]
Nasal/sinus surgery: None / [Procedure, date, outcome]
Tonsillectomy/adenoidectomy: None / [Date]
Thyroid/parathyroid: None / [Procedure]
Neck surgery: None / [Procedure]

Medications

Current medications: [List]
Nasal sprays: [Steroid, antihistamine, decongestant]
Allergy medications: [List]
Anticoagulants: [Drug, indication]

Allergies

[Drug allergies with reactions]

Family History

Hearing loss: No / Yes — [Relationship, age of onset]
Otosclerosis: No / Yes
Head/neck cancer: No / Yes — [Relationship]
Thyroid disease: No / Yes — [Type]
Allergies: No / Yes

Social History

Tobacco: Current / Former / Never — Pack-years: [X]
Alcohol: [Quantity, frequency]
Occupation: [Noise exposure, voice demands]
Noise exposure: [Recreational, occupational]
Voice use: Professional / Heavy / Moderate / Light

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
Temp: [X]°F
SpO2: [X]%

General

Appearance: Well / [Concerns]
Voice quality: Normal / Hoarse / Breathy / Strained

Ear Examination

External Ear:

Finding	Right	Left
Auricle	Normal / [Abnormal]	Normal / [Abnormal]
EAC	Clear / [Cerumen, debris, lesion]	Clear / [Findings]
Tenderness	None / Tragal / Postauricular	None / [Location]

Otoscopy:

Finding	Right	Left
TM	Intact, normal / [Findings]	Intact, normal / [Findings]
Mobility	Normal / Decreased	Normal / Decreased
Effusion	None / Serous / Purulent	None / [Type]
Perforation	None / [Location, size]	None / [Location, size]
Retraction	None / [Grade]	None / [Grade]
Cholesteatoma	None / [Location]	None / [Location]

Pneumatic Otoscopy: Normal mobility / Decreased [R/L] Tuning Fork Tests (512 Hz):

Weber: Midline / Lateralizes [R/L]
Rinne: AC > BC bilaterally / [Abnormal findings]

Nose Examination

External:

Dorsum: Straight / Deviated [Direction]
Tip: Normal / [Findings]
Alar collapse: Absent / Present — Cottle maneuver: [Result]

Anterior Rhinoscopy:

Finding	Right	Left
Septum	Midline / Deviated	[To R/L, location]
Mucosa	Pink, moist / [Pale, erythematous, edematous]	[Findings]
Turbinates	Normal / Hypertrophied	Normal / Hypertrophied
Discharge	None / [Clear, purulent]	None / [Type]
Polyps	None / [Grade]	None / [Grade]
Masses	None / [Description]	None / [Description]

Nasal Endoscopy:

Performed: Yes / No / Deferred

Structure	Right	Left
Middle meatus	Clear / [Polyps, purulence, edema]	[Findings]
Sphenoethmoidal recess	Clear / [Findings]	[Findings]
Nasopharynx	Normal / [Adenoid, mass]

Oral Cavity/Oropharynx

Lips: Normal / [Lesions]
Buccal mucosa: Normal / [Findings]
Teeth/gingiva: Good dentition / [Concerns]
Hard palate: Intact / [Lesions]
Soft palate: Elevates symmetrically / [Asymmetry]
Tongue: Midline / Deviation [Direction], [Lesions]
Floor of mouth: Normal / [Mass, induration]
Tonsils: [Grade 1-4] / Absent — [Asymmetry, exudate, lesion]
Posterior pharynx: Normal / [Cobblestoning, lesions, drainage]

Larynx (Mirror/Flexible Laryngoscopy)

Performed: Yes / No / Deferred
Epiglottis: Normal / [Edema, lesion]
Arytenoids: Symmetric / [Edema, erythema]
False cords: Normal / [Findings]
True vocal cords: Mobile bilaterally / [Paresis, paralysis R/L]

• Appearance: Normal / [Edema, nodules, polyp, leukoplakia, mass]
• Closure: Complete / Incomplete [Gap pattern]

Subglottis: Normal / [Narrowing]
Airway: Patent / [Obstruction]

Neck Examination

Lymphadenopathy:

• Cervical: None / [Level, size, character]
• Supraclavicular: None / [Findings]
• Submandibular: None / [Findings]

Thyroid: Normal / [Enlarged, nodule, tenderness]
Masses: None / [Location, size, mobility, tenderness]
Parotid: Normal / [Mass, tenderness]
Submandibular glands: Normal / [Findings]

Cranial Nerves (ENT-relevant)

VII (Facial): Symmetric / [Weakness — House-Brackmann grade]
IX, X (Palate, gag): Intact / [Asymmetry]
XI (Shoulder shrug, head turn): [5/5] / [Weakness]
XII (Tongue): Midline / [Deviation, atrophy]

Diagnostic Studies Review

Audiometry [Date]

	Right	Left
PTA	[X] dB	[X] dB
SRT	[X] dB	[X] dB
WRS	[X]%	[X]%
Type	[Conductive/SNHL/Mixed]	[Type]
Tympanogram	Type [A/B/C]	Type [A/B/C]

Imaging

CT sinus: [Date, findings]
CT temporal bone: [Date, findings]
MRI IAC: [Date, findings]
Neck CT/MRI: [Date, findings]
Other: [Studies]

Other Studies

Allergy testing: [Results]
Sleep study: [AHI, findings]
Barium swallow/FEES: [Findings]
Fine needle aspiration: [Results]

Assessment

1) [Primary ENT diagnosis]
Severity: [Mild/moderate/severe]
Laterality: [Right/left/bilateral]
2) [Secondary diagnoses]
Differential diagnosis (if applicable):

• [Most likely]
• [Alternative 1]
• [Alternative 2]

Plan

Diagnostic Workup

• [ ] Audiogram with tympanometry
• [ ] CT sinus [Without contrast]
• [ ] CT temporal bone [High resolution]
• [ ] MRI IAC [With gadolinium]
• [ ] Neck CT/MRI [With contrast]
• [ ] Barium swallow / Modified barium swallow
• [ ] FEES (Fiberoptic endoscopic evaluation of swallowing)
• [ ] Allergy testing
• [ ] Sleep study
• [ ] Fine needle aspiration
• [ ] Operative endoscopy with biopsy
• [ ] Other: [Specify]

Medical Treatment

• [ ] Antibiotics: [Drug, dose, duration]
• [ ] Nasal steroids: [Drug]
• [ ] Nasal saline irrigation
• [ ] Oral steroids: [Dose, taper]
• [ ] Antihistamines: [Drug]
• [ ] PPI: [Drug, dose]
• [ ] Vestibular rehabilitation
• [ ] Speech/voice therapy
• [ ] Hearing aids evaluation
• [ ] Other: [Specify]

Surgical Options Discussed

• [ ] Not indicated at this time
• [ ] [Procedure] — Discussed risks/benefits
• [ ] Scheduled: [Date]
• [ ] Patient considering

Referrals

• [ ] Audiology
• [ ] Allergy/immunology
• [ ] Speech-language pathology
• [ ] Vestibular rehabilitation
• [ ] Sleep medicine
• [ ] Neurology
• [ ] Medical oncology
• [ ] Radiation oncology
• [ ] Other: [Specify]

Patient Education

• Diagnosis explanation
• Treatment options discussed
• Medication instructions
• Activity restrictions (if applicable)
• Hearing protection counseling
• Warning signs requiring urgent evaluation

Follow-up

Return: [X] weeks for [Study results, treatment response]
Sooner if: [Specific warning signs]

Communication

Discussed with patient: [Topics covered]
Report sent to: [Referring physician, PCP]