PATIENT HISTORY FORM

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Transcription:

PATIENT HISTORY FORM Name Date of Birth Social Security Number Referring Physician Reason for Visit CURRENT MEDICATION LIST What is the name of the medication? What is the dosage? (i.e. 5 mg) How many tablets do you take at a time? How many times a day do you take this medication? Do you have any allergic reactions to medications? If yes, please describe the medication and the reaction. Do you have any allergic reactions to IODINE, SEAFOOD or X-RAY CONTRAST DYE? If yes, please describe the reaction.

CARDIAC RISK FACTORS Have you ever used tobacco products? If yes, are you still using tobacco products? When did you first start? If you have quit using tobacco products, when did you quit? Describe your tobacco habit (# of packs/week) Do you have high cholesterol/hyperlipidemia? Do you have high blood pressure/hypertension? Do you have diabetes? No Yes Controlled w/diet or medication Unsure PREVIOUS CARDIAC HISTORY Have you ever had any of the following cardiac examinations? No Yes Date Stress Test (EKG/Treadmill) Echocardiogram Holter Monitor Coronary CAT Scan Cardiac Catheterization (Angiogram) Electrophysiology Study (EP Study)

PREVIOUS CARDIAC HISTORY (CONT D) Have you ever had any of the following cardiac events occur? Heart Attack Angioplasty or Stenting in Heart Angioplasty or Stenting in Other Arteries Heart Bypass Surgery Surgery on Other Arteries Heart Valve or Other Heart Surgery Cardioversion Pacemaker Implanted Defibrillator Surgery on Varicose Veins No Yes Date/Description PREVIOUS MEDICAL HISTORY Have you ever had any of the following? No Yes Date/Description Significant Infections or Childhood Illnesses Broken Bones or Severe Injuries Surgeries Any other Medical Problems or Previous Hospitalizations

SOCIAL HISTORY Do you drink any alcohol? If yes, describe your consumption (#of drinks/week) Have you reduced or stopped drinking recently? Do you follow a special diet? Do you exercise regularly? If yes, describe your routine (# of days/week) Do you have a history of drug or alcohol abuse? Are you currently employed? What is your occupation? What is the highest level of education you have received? What is your marital status? Who do you live with?

FAMILY HISTORY Has anyone in your immediate family (Parents/Siblings/Children) had any of the following? Heart Attack Angioplasty Stenting of Arteries Bypass Surgery Blocked Arteries Sudden/Unexplained Death Unexplained Passing Out Spells Heart Rhythm Problems Heart Failure/Weakened Heart Aneurysm of the Brain Aneurysm of the Aorta Stroke Congenital Heart Disease (Birth Defect) Heart Surgery (Other than Bypass) High Cholesterol High Blood Pressure Diabetes Tuberculosis Bleeding Disorder

REVIEW OF SYSTEMS Have you recently had any of the following? Weight Loss Weight Gain Increase/Decrease in Exercise Tolerance Change in Hair/Nails? Rashes or Sores? Double Vision or Blurred Vision Diagnosis of Glaucoma Vision Loss Partial/Complete Hearing Loss Frequent/Unusual Nose Bleeds Hoarseness Problems Swallowing Food/Getting Food Stuck in Throat Food/Liquid Frequently Going Down the Wrong Pipe Shortness of Breath Short of Breath While Lying Down/Waking up Short of Breath GENERAL SKIN EYES EARS/NOSE/MOUTH/THROAT RESPIRATORY

REVIEW OF SYSTEMS (CONT D) Chronic Cough or Wheeze Coughing up Blood Heavy Snoring/Falling Asleep Inappropriately? Been Told that You Stop Breathing While Sleeping? Chest Pain/Tightness/Pressure Palpitations or Irregular Heart Beats Almost Lost or Lost Consciousness Pain/Cramps When Walking History of Blood Clots Swelling in Legs Any Other Cardiovascular Problem History of Ulcers/Intestinal Blood Loss Recent Blood in Stool/Black Stools Frequent Indigestion/Acid Reflux Problems with Diarrhea/Constipation Trouble Urinating Blood in Urine History of Kidneys not Working Well RESPERATORY (CONT D) CARDIOVASCULAR GASTROINTESTINAL GENITOURINARY

REVIEW OF SYSTEMS (CONT D) Unusual Muscle Pain or Tenderness History of Arthritis or Gout Joint or Back Pain Stroke or TIA Recent Loss of Strength or Sensation Loss of Ability to Talk Unusual Headaches Confusion Memory Loss Depression Stress Anxiety Cold Intolerance Heat Intolerance Being Very Thirsty Frequent Urination History of Bleeding Disorder History of Anemia Bruising Easily HIV/AIDS Virus MUSCULOSKELETAL NEUROLOGICAL PSYCHIATRIC ENDOCRINE HEMATOLOGICAL Thank you for taking the time to complete this Patient History Form. Please be sure to review your form, and make sure that each question was answered. The more we can understand about your personal medical history, the better we can serve you moving forward.

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