Name: Date of Birth: Address: City: State: Zip Code: Phone Number: Cell Phone: Work Number: Race: Primary Language: Secondary Language:

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1 Address: Phone Number: Cell Phone: Work Number: Last 4 of SS #: Patient Demographic Information: Gender: Male Female Marital Status Single Married Widowed Divorced Other: Ethnicity Hispanic or Latino Not Hispanic or Latino Unknown Declined to specify Race: Asian Black or African America Native American Indian Native American Indian or Alaska Native Native Hawaiian Other Pacific Islander White Primary Language: Secondary Language: Religion:

2 Emergency Contact Information: Name: Relationship: Address: Phone Number: Cell Phone: Work Number: Medical Care: Primary Care Physician: Phone #: Referring Physician: Phone #: Employment: Employer s Name: Occupation: Employer s Address: Spouse Employer s Name: Occupation: Employer s Address: Insurance Information: Please bring the most update insurance card(s) to your visit. Primary Insurance: Address: Policy Holder Name : Policy Holder DOB: Policy Holder SSN: Insurance ID #: Group #:

3 Reason for your visit: Medications: Please bring a list of CURRENT medication to your visit; include name, dose, and frequency of medication. Allergies and reactions: Pharmacy: Pharmacy Address: Pharmacy Phone #: Do you have an advance directive? Risk Factors: Living Will Medical Durable Power of Attorney Do Not Resuscitate CPR Directive MOST form Other High Blood Pressure No Yes When: Treated: High Cholesterol No Yes When: Treated: Diabetes No Yes When: Treated: Peripheral Artery Disease No Yes When: Treated: Family History of Heart Disease No Yes If yes, fill in the pertain information below Relationship: Age: Type of Heart Disease: Age of Death? Cause of Death? Relationship: Age: Type of Heart Disease: Age of Death? Cause of Death? Relationship: Age: Type of Heart Disease: Age of Death? Cause of Death?

4 Have you ever had any of the follow? Fainting/Dizziness No Yes When: Palpitations/Heart Rhythm Problems No Yes When: Enlarged Heart No Yes When: Heart Murmur No Yes When: Edema (Swelling) Legs No Yes When: Congestive Heart Failure No Yes When: Shortness of Breath No Yes When: Snoring No Yes When: Heart Attack No Yes When: Chest Discomfort/Chest Pain No Yes When: Chest Injury/Trauma No Yes When: Heart Cath/Stent/Angioplasty No Yes When: Pacemaker/ICD Placement No Yes When: Cardiac Bypass Graft Surgery No Yes When: Mini-Stroke or Stroke No Yes When: Claudication (Leg Pain) No Yes When: Deep Vein Thrombosis No Yes When: Bleeding Problems No Yes When: Females Only: Post-menopausal Hysterectomy Hormone Replacement Therapy Have you had any of the following Cardiac Studies? Breast Feeding Pregnant Due Date: EKG No Yes When: Where: Echo or Stress Echo No Yes When: Where: Nuclear Cardiac Study No Yes When: Where:

5 Please list any recent hospitalizations and/or surgery (not listed previously): Lifestyle Diet Low Fat Low Sodium Low Calorie High Fat High Sodium High Calorie Diabetic Healthy Gluten Free No Red Meat Vegan Vegetarian Other: Do you use tobacco? Never Former Current (former and current fill in information below) Type: Packs/day Years Used: Age started: Age Stopped: Ever try to quit: No Yes Years quit: Reason for Relapse: Do you consume caffeinated products? No Yes What kind? How Much? Do you consume alcohol? Never Former Current (former and current fill in information below) What kind? How Much? Frequency: Year quit:

6 Have you used illicit drugs? Never Former Current (former and current fill in information below) What kind? How Much? Frequency: Year quit: Do you regular exercise? No Yes Type: Frequency: Have you recently travel outside the United States? No Yes Where: When:

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