Naresh Patel, MD Texas Health Care Cardiology 508 S. Adams St. Suite 100 Fort Worth, TX Phone: (817) Fax: (817)
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1 Naresh Patel, MD Texas Health Care Cardiology 508 S. Adams St. Suite 100 Fort Worth, TX Phone: (817) Fax: (817) Patient's Name: DOB: Date: What is the reason for your visit? Who is your primary care doctor? Please circle all that apply Do you have chest pain (sharp, dull, burnung) / pressure / tightness / heaviness?... Yes / No How how often do you get CP? times in a days / weeks / months / years / constant How long does the CP last? seconds / minutes / hours / varies / constant Where is the pain? Chest / epigastric / left arm / right arm / shoulder / back / jaw / neck Where does the pain radiate? Left arm / right arm / shoulder / back / jaw / neck / no where Aggravated by exertion / stress / inspiration / lying down / sitting up / movement / None Relieved by rest / nitro / change in position / food / antacid / none Is the pain associated with nausea, vomiting, sweating?... Yes / No Does it hurt when you press on your chest wall?... Yes / No Have you had any recent injuries to your chest wall?... Yes / No Have you had heart surgery?... Yes / No If yes when? Have you had an angiogram, CATH or dye test on your heart?... Yes / No Does it hurt in your legs, thigh or buttocks when you walk?... Yes / No Shortness of breath: Do you get short of breath? Yes / No How how often do you get SOB? times in a days / weeks / months / years / constant How long does the SOB last? seconds / minutes / hours / varies / constant What does it feel like? Pressure / tightness / hard to get air in / air out / squeezing sensation Aggravated by daily activities / exertion / stress / mild activities / stairs / none Relieved by rest / fresh air / nebulizer / sitting / none 1
2 Edema (Swelling): Do you have any swelling? Yes / No Symptoms: aching / coldness / cramping / pain / redness / swelling / none Location: Right / Left / ankle / buttock / calf / thigh / foot Aggravated by: Exercise / rest / smoking / climbing hill / none Releived by? Elevation / warm compress / cold compress / massage / walking / none Additional symptoms? back pain / chest pain / difficulty swallowing / dizziness / headache Palpitations: Do you feel you heart skip beats / irregular heart beats / rapid beats / none How how often? times in a days / weeks / months / years / constant How long does it last? seconds / minutes / hours / varies / constant Aggravated by: exercise / anxiety / stress / caffeine / alcohol / medications / none Relieved by: cough / cold water to face / rest / medications / none Syncope: Do you feel like you are going to pass out or have you passed out? Yes / No Quality: floating/imbalance/light-headedness/spinning/unstable horizon/loss of consiousness Context: sitting to standing / no warning /vertigo / venipunture / other Aggravated by: alcohol/dehydration/change in position/exercise/heat/head turning/none Relieved by: medication / lying down / rest / sitting / none When was your last blood test? Where? When was the last time your cholesterol was tested? Where? Have you been in the hospital recently? Yes / No If yes, which hospital? Have you been seen by a cardiologist in the past? Yes / No If yes, Name? Name of the preferred local pharmacy? Phone: Name of preferred mail in pharmacy? Phone: Your height: Weight: Exercise capacity: Can you walk two blocks rapidly without much chest pain or shortness of breath?... Yes / No Past medical history: (Circle all that apply) Heart disease / heart attack / chest pain / weak heart / congestive heart failure / diabetes / hypertension / high cholesterol / stroke / blockage in your legs / stomach ulcer disease / other: 2
3 Past surgical history: Heart surgery / pacemaker / defibrillator / hysterectomy / appendectomy / other: Family history: Unknown / Adopted Mother: Father: Brothers: Sisters: Children: Social History: Who do you live with at home? # of children Boys Girls What kind of work do you do/did? Do you smoke, or have you ever smoked? Yes / No If yes how much? cigs/packs per day. How old were you when you started? When you quit? Do you drink alcohol? Yes / No What do you drink? How much? Do you drink caffeine? Yes / No What do you drink? How much? Do you follow any type of diet? Yes/ No Low salt / low cholesterol / diabetic / weight loss Do you exrecise? Yes / No How often? What do you do? Medications: Please list all medications you are taking. (If you have your medications with you skip this section) Do you use any street drugs?...yes/ No Do you take aspirin every day?...yes/ No Do you carry Nitro?...Yes/ No Do you take cholesterol meds?...yes/ No Have you taken any diet meds?...yes/ No Are you allergic to any medications? No / Dye / Contrast / Fish Oil / Iodine / Penicillin / Codeine / Morphine / Apirin / Other: 3
4 Review of systems: Do you have any of the following? Cardiac: Chest pain?...yes/ No Abnormal sweating?...yes/ No Palpitations?...Yes/ No Have you passed out?...yes/ No Vascular: Pain in your legs when you walk?...yes/ No Swelling in your legs?...yes/ No Constitutional: Weight gain?...yes/ No Weight loss?...yes/ No HEENT: Changes in your vision?...yes/ No Trouble hearing?...yes/ No Respiratory? Do you snore?...yes/ No Cough up blood?...yes/ No Shortness of breath?...yes/ No Fever?...Yes/ No Gastrointestinal: Nausea?...Yes/ No Acid reflux?...yes/ No Blood in your stools?...yes/ No Genitourinary: Blood in your urine?...yes/ No Use the restroom frequently at night? Yes/ No Neurological? Dizziness?...Yes/ No Memory loss?...yes/ No Seizures?...Yes/ No Pyschiatric: Are you depressed?...yes/ No Hallucinations?...Yes/ No Hematologic: Are you anemic?...yes/ No Abnormal blood count?...yes/ No Endocrine: Thyroid problems?...yes/ No Tremors?...Yes/ No Derm: Skin rash?...yes/ No Skin sores?...yes/ No Musculoskeletal: Joint Pain?...Yes/ No Muscle pain?...yes/ No 4
5 Over the past 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things? Feeling down, depressed or helpless? Trouble falling or staying asleep or sleeping to much? Feeling tired or having little energy? Poor appetite or overeating? Feeling bad about yourself, that you are a failure or have let yourself or your family down? Trouble concentrating on things such as reading the newspaper or watching television? Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been mobing around a lot more that usual? Thoughts that you would be better off dead, or hurting yourself in some way? If you checked off any problems, how difficult have these problems made it for you to do your work, take are of things at home or get along with other people? Not difficult at all / somewhat difficult / very difficult / extremely difficult 5
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