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Personal Information

First Name
Last Name
Gender
Age
Cell Phone Number
Home Phone Number
Work Phone Number

Please review your personal information - then sign your name in the box below using your mouse:

(Use your mouse cursor to sign your name. Click in the box
to the right and hold down the mouse button and drag your
mouse cursor to sign your name. Release the mouse button
when you're done signing your name.)
DO YOU HAVE A LIVING WILL OR A MEDICAL POWER OF ATTORNEY? Yes

What is your reason / chief complaint for making an appointment?

Your Past Medical History :

Arthritis  Diabetes  Phlebitis or Swelling 
Asthma  HIV / AIDS  Rheumatic Fever
Abnormal Heart Rhythm  High Blood Pressure  Blood Clots in Veins or Lungs 
Stroke or "Mini" stroke (TIA)  Thyroid Disorder  Easy Bruising or Bleeding 
High Cholesterol or Triglycerides  Stomach / Intestinal Ulcers  Anemia or Blood Disorder 
Liver Problems / Hepatitis  Menopause  Heart Failure 
Heart Murmur  Vascular Disease  Cancer 
Kidney Disorder  COPD / Emphysema  Heart Attack 

Your Cardiac & Non-Cardiac Past Surgical History

*Please include the date of your surgery.
 

Your Cardio Vascular Testing and Surgical History

EKG or Stress Test Pacemaker / ICD
Echocardiogram Angiogram (heart cauterization)
Nuclear Testing Coronary Angioplasty (balloon) / Stents
Vascular Testing Bypass Surgery
Event / Holter Monitor Peripheral Arterial Procedures
Heartsaver CT Valve Repair or Replacement
Cardioversion Heart Transplant
Electrophysiology Study / Ablation  

Allergies:

Do you have allergies?
Have you had a reaction to x-ray contrast dye?
Are you allergic to iodine or shellfish?
Are you allergic to any medications?
(If yes, please list medication names)
 

Your Family's Medical History: Please check all that apply.

Heart Attack Stroke Congenital Heart Disease Heart Failure Diabetes
High Cholesterol High Blood Pressure Kidney Failure Blood Clots / Bleeding Problem Vascular Disease

Please list the family member and their medical history.


Have any blood relatives had heart bypass surgery, heart stent/balloon procedures, or heart attacks? If so, list the person, what procedure and their age at the time of the procedure.

 

Your Social History and Habits

Martial Status
Are you employed?
Occupation - What is your occupation?
Did you ever smoke tobacco?  
How many packs and for how many years?  Number of Packs Per Day Years Smoking
Do you drink alcohol (including beer)?  How many drinks / beer per day? 
Caffeine - How many caffeinated beverages do you drink per day?
Drug Use - Have you ever used intravenous drugs or cocaine?
Have you ever used other illegal drugs or been addicted to prescription pain medications?
Do you take decongestants?
Diet - Do you follow a particular diet? If so, please describe:
Stress Issues - Please describe the issues you're experiencing:

A review of your clinical systems - Please check all that apply

Constitutional: Fever Night Sweats Weight Gain (How Many lbs? ) Weight Loss (How Many lbs? ) Exercise Intolerance Chills
Eyes: Dry Eyes Irritation Vision Change
Ears: Difficulty Hearing Ear Pain
Nose: Frequent Nosebleeds Nose/Sinus Problems
Mouth/Throat: Bleeding Gums Snoring Oral Abnormalities Teeth Abnormailities
Cardiovascular: Chest Pain on Exertion, Arm Pain on Exertion Shortness of Breath When Walking Shortness of Breath When Lying Down Palpitations Known Heart Murmur Light-headed on Standing
Respiratory: Cough Wheezing Shortness of Breath Coughing up Blood History of Sleep Apnea
Gastrointestinal: Abdominal Pain Vomiting Change in Appetite Black or Tarry Stools Frequent Diarrhea Vomiting Blood
Genitourinary: Urinary Loss of Control Difficulty Urinating Increased Urinary Frequency Hematuria Incomplete Emptying
Musculoskeletal: Muscle Aches Muscle Weakness Arthralgias/Joint Pain Back Pain Swelling In The Extremities
Integumentary: Rash Itching Dry Skin
Neurologic: Loss of Consciousness Weakness Numbness Seizures Dizziness Frequent or Severe Headaches Migraines Restless Legs
Endocrine: Diabetes Mellitus Type 2 Fatigue Increased Thirst Hair Loss Increased Hair Growth Cold Intolerance Excessive Sweating
Psychiatric: Depression Sleep Disturbances Alcohol Abuse Insomnia
Hematologic/Lymphatic: Easy Bruising Excessive Bleeding Anemia
Allergic/Immunologic: Runny Nose Sinus Pressure Itching Hives Frequent Sneezing

List Medications You Currently Take ( Include any "as needed" or over the counter medications)

Name Of Medication Dose (mg, Units) Times per Day (AM/PM, # of tabs, etc.)
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