We are looking forward to meeting with you and assisting in your cardiac care. Thank you, Metropolitan Heart and Vascular Institute.
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1 Thank you for scheduling an appointment at Metropolitan Heart and Vascular Institute. We are looking forward to meeting you. Enclosed are our patient registration forms. Please complete these forms to the best of your knowledge and bring them with you on the day of your appointment. Medical Records: It is very important that we have information regarding your past medical and cardiac care. This includes any procedures, surgeries, labs, EKG s, imaging studies or office visits. We request any films be sent on CD- ROM. Your records can be faxed to us at If you are an Allina Medical Clinic (AMC) patient, your records are already available to us through your electronic medical record. If you are not an AMC patient, please arrange to have your records sent to us. In addition, we would like you to fill out the Health Information Worksheet, Family History form and your medication list that are enclosed. Having these forms completed prior to your visit will help expedite the check in process. Insurance: Please bring your current insurance card(s) with you to your appointment. If your insurance plan requires a co-pay, it will be due at the time of service. If your insurance plan requires a referral, you are responsible for obtaining this referral from your primary care provider/clinic prior to your appointment. Scheduling and Punctuality: We ask that you allow plenty of time to get to the office for your appointment. You may be asked to reschedule your appointment if you are more than 15 minutes late. From time to time, a patient emergency arises and we may be running late for your visit, if this occurs, you will have the option to re-schedule or stay to be seen. We understand circumstances may arise which make it impossible for you to keep a scheduled appointment. Should this happen in the future, call us as soon as you know the appointment will be missed. The earlier you let us know, the more likely we can offer your scheduled appointment time to another patient. If you need to cancel your appointment, we request at least a 24 hour notice. To cancel your appointment please call What to Expect: The first time you come in we will be gathering information regarding your previous care and your current situation and/or symptoms. We will not be doing any testing on that day. The physician will determine which test you may need and how urgent they are. If your cardiac provider prescribes you medications it is important that you see us yearly so we can make sure you are safe and receiving the proper dosage of medication. When you are down to one refill on your medication, we ask that you call and schedule your follow-up office visit in order to be evaluated and have your medications adjusted or refilled. Please allow enough time for us to make an appointment so you re not without your medication. If you have any further questions or believe you will be unable to get the requested information in a timely fashion, please call our main switchboard at and we will be happy to assist you. We are looking forward to meeting with you and assisting in your cardiac care. Thank you, Metropolitan Heart and Vascular Institute Nursing Staff
2 Metropolitan Heart & Vascular Institute Health Information Worksheet: Name: Please bring your up-to-date (latest) medication list OR all your medication bottles to your clinic visits. General Have you experienced an unexplained weight loss of greater than 10 pounds in the past three months? Yes No Have you experienced an unexplained weight gain of more than 10 pounds in the past three months? Do you have or have you had cancer? Yes No Respiratory Do you have a cough? Yes No Do you wheeze? Do you have lung disease? Cardiovascular If so, which do you have? Asthma COPD Emphysema Do you experience chest pain? Do you experience shortness-of-breath with exertion or activity? (dyspnea) Does your heart race, skip beats, or beat irregularly? (palpitations) Have you passed out or lost consciousness in the past year? (syncope) Do you experience swelling in your legs or ankles? (edema) Do you experience cramping or aching in your calves or legs with walking? (claudication) Gastrointestinal Do you have blood in your bowel movements? Have you vomited blood within the last six months? Do you have abdominal pain AFTER eating? Do you have trouble with any of the following? heartburn, reflux, GERD or ulcers? OVER
3 Genitourinary Do you have blood in your urine? Do you have kidney disease or kidney failure? Neurological Have you ever had a stroke, paralysis, mini-stroke, TIA? Do you have a problem with dizziness or fainting? Have you had any problem with speaking such as garbled speech or difficulty with word finding? Eye Have you had any vision changes within the last six months? Ear, Nose and Throat Do you experience any ringing in your ears? Do you experience vertigo? (dizziness) Musculoskeletal Do you have arthritis? Do you have muscle aches? Skin Do you have a skin rash or skin condition? Psychological Do you have depression or a history of depression? Do you have dementia? Yes No Endocrine Do you have a thyroid problem? Do you have diabetes? Yes No
4 4040 Coon Rapids Blvd, Coon Rapids, MN Family Status Alive Good Health Deceased Age of Death Mother Father Sister/s (# _) Brother/s (# ) Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Children (Son# /Daughter# ) Alcohol Addiction/Drug Abuse Problems with Anesthesia Arthritis Asthma Blood Disorder Diabetes Genetic Disorder Stomach/GI Issues Bladder/Kidney disease High Blood Pressure Family Conditions Mother Father Sister Brother Other (Please list relation) Coronary Heart Disease/ Heart Attack High Cholesterol Psychiatric Issues/Mental Illness Stroke Seizure Disorder Thyroid Disorders Cancer Type: Metropolitan Heart & Vascular Institute 10_13
5 Medication List Please list all medications you are currently taking Including any prescriptions. Over the-counter medications. Herbs. Supplements Name Dosage When do you take it List any allergies to medication and the symptoms: Medications Symptoms Name of Pharmacy you would like prescriptions sent to: Address: Phone Number:
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DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
Unity Memory Clinic. Please fill out this form and bring it to your appointment. Name of patient: Last First MI. Male Female Date of Birth:
Unity Memory Clinic Patient information Name of patient: Please fill out this form and bring it to your appointment Last First MI Male Female Date of Birth: Caregiver/Contact Person Information Name of
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem: