UnityPoint Clinic - Cardiology
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1 UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset: Doctors seen in past year: Family History: Father Mother Age Serious Health Problems Age at Death if deceased Cause Brother(s) Sisters(s) Children Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother DM-FORM
2 Social History: Single Married Widowed Divorced Education: Last grade of school completed: Current/Prior Occupation: Do you smoke cigarettes? Do you chew tobacco? Do you drink alcohol? Do you use illegal drugs? Do you drink caffeine? Past Medical History: Do you have or have you been treated for: Alcoholism Depression Kidney Disease Anemia Diabetes Liver Disease Anxiety Emphysema Migraine Headaches Arrhythmias Fainting Pneumonia Arthritis Glaucoma Polio Asthma Gout Rheumatic Fever Bleeding Disorder Heart Attack Scarlet Fever Bronchitis Heart Murmurs Sleep Apnea Cancer Hepatitis Stroke Cataracts Hiatal Hernia Thyroid Problems Congestive Heart Failure High Blood Pressure Tuberculosis CPAP High Cholesterol Ulcers Other (please list) Past History/Major Illnesses and Date (use reverse if needed) Hospitalizations (include surgeries): 1. Where When How Long 2. Where When How Long 3. Where When How Long Have you had the following tests done: Chest x-ray where When EKG where When Echocardiogram where When Treadmill where When Nuclear Stress Test where When Carotid Duplex where When Other Ultrasound where When Angiogram/Stents where When CAT Scan where When
3 Medications: PLEASE BRING ALL MEDICATIONS WITH YOU TO YOUR VISIT WITH THE DOCTOR Name of Drug Dose (include strength and How long have you number of pills per day) taken this medication? Allergies (Please describe any reactions to medications): Review of Systems (check Yes if this applies to you): Musculoskeletal Yes Describe Pain or weakness: Upper limbs Lower Limbs Joints Falls Neurology Memory difficulties Headaches Numbness/tingling Balance difficulty Seizures Weakness Genitourinary Frequent urination Painful urination Blood in urine Difficulty starting urine stream Sexual dysfunction
4 Hematologic Yes Describe Easy bruising Fever/chills Sweats Psychiatric Anxiety Depression Cardiovascular Chest Pain: Please describe the approximate time pain began, the frequency, duration, what makes the pain start, and what makes the pain go away, in each box below. Sharp Tightness Heaviness Pressure At Rest With Exertion Right chest Left Chest Mid-chest Whole Chest Left/right arm pain Nausea Jaw Pain Shortness of Breath At rest With exercise Swelling of legs Lightheadness Blood clots Pacemaker/defibrillator Respiratory Cough Difficulty breathing Wheezing Night Sweats Gastrointestinal Appetite poor/change Constipation Diarrhea Abdominal Pain Nausea/vomiting Bloody or black stools Constitutional Recent weight change Change in energy level/fatigue Difficulty falling asleep or staying asleep Recurrent fevers/sweats
5 Eyes, Ears, Throat Yes Describe Double vision Loss of vision Blurred vision Sore throat Difficulty swallowing Difficult speaking Hearing change Nosebleed Sinus Problem Bleeding of gums Endocrine Excessive thirst Hair loss Pregnancy Menopausal symptoms Abnormal menstrual cycle Skin Itching Skin sores Rashes Discoloration Signature Date
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
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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
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
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Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
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DATE OF BIRTH: MELANOMA INTAKE
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