DIVISION OF CARDIOLOGY
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- Clare Phyllis Henry
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1 Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address: Work #: Fax #: Pharmacy: Address: Phone #: Fax #: Medication prescription preference (circle one): 30 day supply 90 day supply Will you need translation services during your visit? Yes: No: If yes, please list the language required: Please note: We strongly recommend an English-speaking family member accompany you to your visit. Why are you here to see a cardiologist today? Please be as specific as possible (e.g., symptoms or tests.) Do you currently smoke? Yes: No: Did you ever smoke? Yes: No: Did you ever use chewing tobacco or snuff? Yes: No: (If yes to any question, please indicate type of tobacco, amount per day, number of years, and quit date.) Do you currently drink? Yes: No: (If yes, please indicate type(s) of alcohol and approximate number of drinks per week for each type.) Are you: Married Single Divorced Widowed Other: Do you currently work? Yes: No: Occupation: Have you ever had non-cardiac surgery before? Yes: No: If yes, please indicate dates and types of surgery: Page 1 of 5
2 PAST MEDICAL HISTORY: Do you personally have a history of: Known coronary artery disease? - "silent" heart attack (found incidentally) - heart attack(s) requiring hospitalization - coronary artery stenting - coronary artery ballooning only - coronary artery bypass surgery Heart rhythm disorders? - pacemaker? - defibrillator (ICD)? - atrial fibrillation? - atrial flutter? - ventricular arrhythmias? - cardioversion? - ablation procedure? Heart failure? A heart murmur? Mitral valve prolapse? Rheumatic heart disease? High blood pressure (even if treated)? High cholesterol (even if treated)? Diabetes (even if treated)? Stroke? Aortic aneurysm (an enlarged aorta)? Thyroid disorder (hyper or hypo)? Asthma/Emphysema/COPD? Stomach/peptic ulcers? Gastrointestinal bleeding? Heartburn/Reflux (GERD)? Lung cancer? Colon cancer? Breast cancer? Prostate cancer? History of a blood clot (DVT/PE)? Bleeding disorder? PAST SURGICAL HISTORY: Heart valve repair? Heart valve replacement? Carotid artery surgery (endarterectomy)? Aortic aneurym repair/stenting? Peripheral artery bypass surgery? Congenital heart disease repair of: - Tetralogy of Fallot - atrial septal defect - ventricular septal defect YES NO DETAILS (e.g., dates, hospitals, treating physicians) Page 2 of 5
3 Please indicate your family members medical history as below: First Name Alive? (Y/N) Age Heart Disease? High Cholesterol? Diabetes? Stroke? Cancer? Emphysema or asthma? Father Mother Brother(s) Sister(s) Son(s) Daughter(s) Other(s) For any family member you have indicated yes for heart disease above, please list the specific details below (e.g., heart attack, stents, bypass surgery, valve disease, atrial fibrillation, etc.) as well as the age of onset of the disease. If any family member died suddenly please indicate the age at death and if the cause was heart-related (e.g., heart attack, sudden death, stroke, etc.) Family member Age at onset/death Type of heart disease/cause of death Do you have a living will? Yes: No: Do you have a health care proxy? Yes: No: If yes, please list contact information below: Name: Relation: Address: Home Phone #: Cell Phone #: Work Phone #: Fax # (if applicable): address: Page 3 of 5
4 Do you have any ALLERGIES to medications? Yes: No: If yes, please list medicaitons AND reactions: DIVISION OF CARDIOLOGY Please list ALL of your CURRENT medications below (if you need more room please use back of page): Medication (name) Amount Frequency taken (daily, every 6 hours, etc.) Approximate start date of medication Example: metoprolol 25 mg Once daily 2005 Do you take any non prescription medications? Yes: No: If yes, please list below: Page 4 of 5
5 REVIEW OF SYSTEMS: Please indicate IF YOU ARE CURRENTLY EXPERIENCING any of the following signs and/or symptoms: YES NO YES NO CONSTITUTIONAL MUSCULOSKELETAL Recent change in weight? Pains in the joints (knees, hips, etc.)? Fevers? Muscle pains? Chills? Bone fractures? Night sweats? Pain in the bones (not joints)? Decreased appetite? GENITOURINARY Fatigue? Need to urinate frequently? Inability to sleep? Need to urinate suddenly and urgently? EYES Frequent urination at night (>1X)? Recent change in vision? Blood in the urine? Double vision? Pain while urinating? Eye pain? Urinary incontinence? EARS/NOSE/MOUTH/THROAT DERMATOLOGICAL Hearing loss? New rashes? Ringing in the ears? New ulcers? Pain in the ears? Recent hair loss? Nasal congestion? Recent change in skin? Runny nose? NEUROLOGICAL Post nasal drip? New weakness? Nosebleeds? New severe headaches? Sore throat? New memory loss? CARDIOVASCULAR New seizures? Chest pains? Sensation of the world spinning? Palpitations? ENDOCRINOLOGIC Inability to sleep lying flat? New intolerance to heat? Swelling in the legs or feet? New intolerance to cold? Muscle pains in the legs with walking? Increased frequency of urination? Awakening feeling short of breath? Increased need to drink fluids? Lightheadedness? HEMATOLOGICAL Loss of consciousness? Easy bleeding? Decreasing exercise tolerance? Easy bruising? RESPIRATORY Swollen glands/lymph nodes? Shortness of breath? Current use of coumadin/pradaxa/xarelto? Coughing up sputum/phlegm? ALLERGIC/IMMUNOLOGIC Coughing up blood? Diffuse itching? Wheezing? Anaphylaxis? GASTROINTESTINAL Swelling of the throat? Nausea? PSYCHIATRIC Vomiting? Depressed mood? Abdominal pains? Inability to enjoy anything? Diarrhea? Anxiety? Constipation? Suicidal thoughts? Heartburn/reflux? Hallucinations? Blood in the stool? Page 5 of 5
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