Your information is important to us, Please PRINT Clearly
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- Franklin Bruce
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1 Surgeon: Argenziano aka Williams Takayama Smith Stewart ew ork Presbyterian Hospital Cardiothoracic Surgery Patient History Form M Date our information is important to us, Please PIT Clearly Please Mark Ovals with: X ast ame Middle Initial First ame Street Address Apt. City State Zip Code Home Phone Work Phone Occupation Age Height ' " Weight lbs Sex M M F Marital Status S M D W Cardiologist eferring Physician eason for Visit epair of Congenital Defect Aneurysm epair Valve Surgery Diagnostic Evaluation Bypass Surgery Other Allergies Penicillin Contrast Dye Shellfish Sulfa atex Iodine o known drug or latex allergies Smoking/Alcohol Use Do you currently use tobacco? Did you quit smoking? If es, How Many Packs Per # ears Smoked ear - - Packs Per # ears Smoked Current Drug use? Describe Alcohol use? arely umber Drinks/ umber Drinks/ Week Current Vitamins/Supplements Folic Acid Iron Multi-Vitamin Vitamin E
2 Print umbers in the boxes. For Example: Medications exium Atenolol (opressor) Toprol X (metoprolol) Diovan (valsartan) ipitor (atorvastatin) Dosage per Tablet Times/ Hydrocholorothiazide (HCTZ) anoxin (digoxin) furosemide (asix) Potassium Aspirin (Ecotrin) 10 meq 20 meq meq Plavix (clopidogrel) 75 Coumadin (warfarin) Mon Tue Wed Thur Fri Sat Sun Insulin 1. With Meals Or AM units PM units As eeded Units Insulin 2. Please ist our Other Medications here Dosage Per Tablet Times/
3 Please enter dates using the following format: Past Medications Please list any medications you have stopped taking during the past year: ear Please mark X next to any of the following tests or procedures you have had: ear Where did you have the test/procedure? Echocardiogram Stress Test Cardiac Catheterization Previous Heart Surgery Angioplasty Stenting Pacemaker Defibrillator (AICD) Make Model Date of last generator change: ear ist All Other Surgeries and Dates Here ear
4 Please enter dates using the following format: ear Date of First Occurence Heart Murmur ear Endocarditis heumatic Fever Irregular Heart hythm High Blood Pressure Elevated Cholesterol Heart Attack Congestive Heart Failure (CHF) Abnormal EKG Ankle Swelling Chest Pain if yes, at rest w/ exercise while asleep Shortness of Breath if yes, at rest w/ exercise while asleep History of problems with your ungs Chronic Cough Abnormal Chest X-ay Bronchitis Use Inhalers Emphysema Asthma Currently Take Steroids Took Steroids in past ast Used ear Pneumonia Pulmonary Function Tests? When COPD Where did you have the test? ung Cancer
5 Please Mark Ovals with: X History of problems with your Arteries/Veins/Circulation Easy Bruising Problems with your blood/clotting eg Cramps w/ Walking Sickle Cell Anemia Bleeding Tendency ear Previous Transfusion eg Varicose Veins Vein Stripping ear Heart Surgery w/ eg Vein Harvest History of problems with your Kidneys/Bladder/Prostate Frequent Urination Prostate Disease Difficulty Urinating Kidney Stones Frequent Urinary Tract Infections Kidney Disease Dialysis How often? M T W Th F Sa Su Surgery on: ear Prostate Bladder
6 Ulcers Please Mark Ovals with: History of problems with your iver/gi System/Stomach Jaundice X Bleeding Ulcers Blood in Stool Pancreatitis Hepatitis A B C ear History of problems with your eurological/musculoskeletal system Arthritis Fainting Muscle Weakness eck/back Injury Seizures Stroke Date ear Describe eck/back Injury Other Medical History Glasses oose/capped/missing/chipped Teeth Dentures or Bridges: emovable Permanent Contacts Cancer Type Glaucoma Hearing Problems Diabetes Date Diabetes diagnosed ear Gout Diabetes Controlled with: Thyroid Disease Diet Controlled Oral Meds Insulin Extreme Anxiety Psychiatric Illness
7 T H A K O U! Family Medical History Mark if Diagnosed with Heart Age Disease Cause of Death Mother Father Brother(s) Sister(s) PEASE ADD A ADDITIOA MEDICA HISTO IFOMATIO BEOW
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist
Name of Pa. tient: Last. First. per day) 50 mg. X-ray dye or. IV contract. Name (Last) (First) Address. City, state/ zip code
Division of Cardiology for the Academic Medical Center of the University of Texas Medical School at Houston NEW PATIENT HISTORY FORM Please complete and fax to 713-512-2245 Name of Pa tient: Last _ First
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Patient Health History
Patient Health History This information is very important in your care. Please complete as carefully and accurately as possible. Name: Date: Height: inches Weight: lbs Age: Symptoms: 1. Type of symptoms
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
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ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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