Nose, Sinus, Larynx, and Pharynx

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Including Prior Treatment and Subjective Complaints):

1. Location and nature of the injury or disease.
2. Treatment - type (e.g., surgery, medication, oxygen, respirator, etc.) frequency, duration, response, and side effects.
3. Subjective Complaints

Comment on presence or absence of each of the following:

1. Interference with breathing through nose.
2. Purulent discharge.
3. If speech impairment (ability to communicate by speech, ability to speak above a whisper, etc.).
4. For chronic sinusitis, indicate whether pain, headaches, purulent discharge or crusting are present. Describe frequency of episodes. Number of incapacitating episodes per year (defined as requiring bedrest and treatment by a physician) necessitating prolonged (lasting 4-6 weeks) antibiotic treatment. Number of non-incapacitating episodes per year.
5. Other symptoms reported.

4. Effects of condition on occupational functioning and activities of daily living.
5. History of neoplasm.

1. Date of diagnosis, diagnosis.
2. Benign or malignant.
3. Type and dates of treatment.
4. Last date of treatment.

C. Physical Examination (Objective Findings):

Perform complete examination of area affected by disease and/or injury. Report all findings. Additionally, comment on presence or absence of each of the following:

1. For allergic and vasomotor rhinitis, indicate whether nasal polyps are present.
2. For bacterial rhinitis: Indicate whether there is evidence of permanent hypertrophy of turbinates, granulomatous disease including rhinoscleroma.
3. When there is obstruction (partial or complete) of one or both nostrils, indicate percent of obstruction for each.
4. Is there septal deviation?
5. Is there tissue loss, scarring or deformity of the nose?
6. Sinusitis - Describe tenderness, purulent discharge, or crusting and sinus (es) affected.
7. For disease or injury affecting the soft palate, is there nasal regurgitation or speech impairment?
8. For larynx: Describe current appearance of larynx. Indicate whether there has been a laryngectomy, partial or total.
9. For pharynx: Describe any residuals of injury or disease.

D. Diagnostic and Clinical Tests:

1. If there is stenosis of larynx, order FEV-1 with flow-volume loop.
2. If there is facial disfigurement, order color photographs.
3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Comment on whether the disease primarily involves or originates from the nose, sinus, larynx, or pharynx.