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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.

Sign your name in the box
below using your finger:

(Use your finger to sign your name.
Press an area in the box hold down
your finger, and drag your
finger to sign your name. Release
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?
Years Smoking
Number of Packs Per Day?
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
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 #1
Dose (mg, Units)
Times per Day (AM/PM, # of tabs, etc.)
 
Name Of Medication #2
Dose (mg, Units)
Times per Day (AM/PM, # of tabs, etc.)
 
Name Of Medication #3
Dose (mg, Units)
Times per Day (AM/PM, # of tabs, etc.)
 
Name Of Medication #4
Dose (mg, Units)
Times per Day (AM/PM, # of tabs, etc.)
 
Name Of Medication #5
Dose (mg, Units)
Times per Day (AM/PM, # of tabs, etc.)
 
Name Of Medication #6
Dose (mg, Units)
Times per Day (AM/PM, # of tabs, etc.)
 
Name Of Medication #7
Dose (mg, Units)
Times per Day (AM/PM, # of tabs, etc.)
 
Name Of Medication #8
Dose (mg, Units)
Times per Day (AM/PM, # of tabs, etc.)
 
Name Of Medication #9
Dose (mg, Units)
Times per Day (AM/PM, # of tabs, etc.)
 
Name Of Medication #10
Dose (mg, Units)
Times per Day (AM/PM, # of tabs, etc.)

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