Steve Y Kim, MD
Ears, Nose, and Throat
161-14 Northern Blvd. 1st FL, Flushing, NY 11358 · (718) 661-2046
2185 Lemoine Ave. #1P, Fort Lee, NJ 07024 · (201) 569-9130
New Patient Registration & Medical History
Today's date
Office: ☐ Flushing, NY ☐ Fort Lee, NJ
Patient Information
Last nameFirst nameM.I.
Date of birthSex: ☐ M ☐ F ☐ OtherPreferred language
Street address
CityStateZIP
Cell phoneEmail
Referring physicianPrimary care physician
Emergency contactRelationshipPhone
Insurance
Primary insuranceMember ID
Policy holder namePolicy holder date of birth
Secondary insuranceMember ID
Please bring your insurance card(s) and a photo ID to your visit.
Reason for Visit
What brings you in today?
How long have you had this problem?Which side? ☐ Left ☐ Right ☐ Both
Current Symptoms (check all that apply)
Ears
☐ Hearing loss☐ Ringing (tinnitus)☐ Ear pain☐ Drainage☐ Fullness / pressure☐ Wax build-up
Balance
☐ Dizziness☐ Spinning (vertigo)☐ Unsteadiness☐ Motion sensitivity
Nose & Sinus
☐ Congestion☐ Sinus pressure☐ Post-nasal drip☐ Nosebleeds☐ Loss of smell☐ Snoring☐ Seasonal allergies
Throat & Voice
☐ Sore throat☐ Hoarseness☐ Trouble swallowing☐ Heartburn / reflux☐ Chronic cough
Head & Neck
☐ Neck lump☐ Thyroid problem☐ Facial pain☐ Headaches
Medical History
☐ High blood pressure☐ Diabetes☐ Heart disease☐ Asthma☐ Stroke☐ Bleeding disorder☐ Cancer☐ Thyroid disease☐ Sleep apnea☐ Pregnant
Other conditions
Past surgeries (with dates)
Medications & Allergies
Current medications and doses
Blood thinners? ☐ No ☐ Yes (aspirin, Coumadin, Eliquis, etc.)Which one(s)?
Drug allergies ☐ None knownReaction
Other allergies (food, latex, environmental)Reaction
Preferred pharmacyPharmacy phone / location
Social History
Tobacco: ☐ Never ☐ Former ☐ Current
Alcohol: ☐ No ☐ Yes
Occupation
Family history of hearing loss, ENT, or head & neck problems
Anything Else We Should Know?
Authorization
I certify that the information above is accurate to the best of my knowledge. I authorize Steve Y Kim, MD to provide treatment, to release information needed to process insurance claims, and to receive payment directly from my insurance carrier. I understand that I am financially responsible for any balance not covered by insurance.
Patient (or guardian) signatureDate
If signed by guardian, print nameRelationship to patient