Medical History Step 1 of 4 25% Current SymptomsCheck all that applyHEAD-SINUSES Facial Pain Headaches Pressure Congestion Bleeding Sneezing Runny Nose Loss of Smell Itching Post Nasal Drainage EARS-HEARING Pain Hearing Loss Ringing in Ears Pressure Loss of Balance Itching Drainage Ear Wax MOUTH Dental Problems Dry Mouth Bad Breath Cold Sores Ulcerations Parotitus Bleeding THROAT Sore Hoarseness Loss of Taste Bad Breath White Spots Lesions Snoring Difficulty Swallowing RESPIRATORY Shortness of Breath Coughing Wheezing Asthma GI Heartburn Reflux Diarrhea Nausea Vomiting Gastritis NEUROLOGICAL Headaches Passing out Dizziness Numbness CONSTITUTIONAL SYMPTOMS Fatigue Fever Chills Night Sweat Weight Loss or Gain Fainting EYES Double Vision Itching Vision Loss Pain Burning Tearing Dry Eyes SKIN Rash Itching Lesions Hives MUSCULOSKELETAL Joint Pain Jaw Pain HEMATOLOGIC-LYMPHATIC Neck Mass Bruising Do you have any Medical Problems?*YesNoPlease list Medical Problems*DateCondition Do you have any Auto-Immune Diseases?*YesNoPlease list Auto-Immune Diseases*DateCondition Do you have a Psychiatric History?*YesNoPast Psychiatric History*DateCondition Do you have a Family History of Bleeding Disorders*YesNoDo you have a Family History of having a Reaction to Anesthesia*YesNoFamily History Details*Family RelationshipDetails Do you have any Allergies?*YesNoPlease list all allergies bellow (including medication, environmental, and/or food related allergies)* Are you currently taking any medications?*YesNoList all medications with mg you are currently taking (including all over the counter medications, diet pills, vitamins, and herbal remedies)*MedicationDosage Are you currently using tobacco products?*YesNoWhat is the quantity per day?*Have you previously used tobacco products?*YesNoWhat was the frequency per day?*For how long?*Are you currently using Marijuana products?*YesNoWhat is the quantity per day?*Have you previously used Marijuana products?*YesNoWhat was the frequency per day?*For how long?*Do you drink alcohol?*YesNoAmount?*How often?*Do you currently or have you in the past had a problem with substance abuse?*YesNoPast Problems*DateSubstance TypeTreatmentTreatment Provider * The above medical history is accurate to the best of my knowledge. Nose HistoryPlease answer the following questions as accurately / honestly as possible in order for Dr. Murray to give you the best recommendations.Have you had any type of nasal surgery in the past?*YesNoPast Nasal Surgery Details?*DateType of surgerySurgeon name Do you have any implants in your nose?*YesNoWhat kinds of Nasal Implants?*Have you had any fillers injected into your nose?*YesNoWhen, type of filler, injector name for each*DateFiller TypeInjector Name Do you have any issues breathing through the nose?*YesNoWhich Side(s)?* Left Right Both Does the congestion alternate sides?*YesNoWhat are your main goals in terms of aesthetic improvements to the nose?*Are you looking for a natural or a more aggressively stylized look?*NaturalAggressiveAny other description of the “type of nose” you are looking for?Upload ImagesPlease upload any image you feel would help describe your needs Drop files here or Accepted file types: jpg, gif, png, tiff.