HEART CENTER OF NORTH TEXAS, P.A. CARDIOLOGY

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Transcription:

HEART CENTER OF NORTH TEXAS, P.A. CARDIOLOGY Dear Welcome to the Heart Center of North Texas. Your appointment has been scheduled for at with Dr. Mott. Your appointment will be at our Weatherford office located at 920 Hilltop Drive, behind the post office. Please fill out the following paperwork and bring it with you to your appointment along with your drivers' license or picture ID and your insurance cards. Please do not mail back this paperwork. If for any reason you are unable to keep this appointment please contact our office at 817-334-2800 and we will gladly reschedule your appointment to a more convenient time. NOTE: If your insurance requires a referral, you are responsible for notifying your primary doctor so they can obtain one. If we do not receive the referral by your appointment time, you will be rescheduled. Thank you, Heart Center of North Texas PLEASE BRING A LIST OF ALL MEDICATIONS WITH YOU TO YOUR APPOINTMENT 1017 12TH AVENUE FORT WORTH, TEXAS, 76104 P: 817-334-2800 F: 817-820-0094 920 HILLTOP DRIVE WEATHERFORD, TEXAS 76086 P: 817-334-2800 F: 817-613-8590

Heart Center of North Texas Cardiovascular Consultation Clinic Primary Physician: Choose one: Retired/ Disabled/ Occupation: Reason you are being evaluated by a heart specialist? Discomfort possibly related to your heart Prior heart attack date: Heart failure Passing out Abnormal EKG (electrocardiogram) High blood pressure Fast or slow heart rate Abnormal heart sound or murmur Other heart surgery Shortness of breath Decreased exercise tolerance Edema (swelling) Irregular heart rhythm Stress testing High cholesterol Palpitations Prior bypass surgery Do you have any risk factors for heart disease listed below? Past tobacco use (any type) High cholesterol or triglycerides Current tobacco use High blood pressure Family history of heart disease Family history of sudden death Low fat diet Low activity level Diabetes (high blood sugars) Postmenopausal woman on estrogen? High stress lifestyle Overweight Please list ALL medical diagnosis/history/problems for which you have been treated. Past and present. Please list ALL prior surgical procedures you have had. Have you previously had Heart cath/angiogram Echocardiogram/Ultrasound Stress test Nuclear (thallium or cardiolite) Rhythm or holter monitor Cholesterol check Chest X-ray EKG (approximately when/where/do you know the results)

Page 2: Name: DOB: What medications do you currently take (include prescription and non-prescription drugs) **PLEASE BRING ALL YOUR MEDICATIONS OR A CURRENT LIST WITH YOU** Medication, Dosage, Etc: What pharmacy do you use? Local &/ Mailorder: ------------------------- Where: ----------------------------- Allergies: Medications no yes Iodine/IV Foods no yes no yes Diabetes: yes no Type: One Two Year Diagnosed: Marital Status Married Single Divorced Widowed Other Children None x boys x girls Tobacco History yes no former Tobacco Type: packs per day. Do you still smoke # years smoked When did you quit

Primary Language English Spanish Other Residence, what is your current living arrangements? Assisted living With family With spouse Alone Other Are you on a special diet? Regular Low fat Diabetic Other Are you able to be as active as you want to be? yes no If not, why? Do you have any limitations ie: wheelchair, walker Alcohol History Never Frequent Moderate Occasional Past problem Drug History Caffeine Never Current problem Past problem Drug Type: Quit: Cokes Coffee Tea Chocolate Caffeine pills Family Medical History: Mother: Heart Disease High Blood Pressure Stroke Diabetes Cancer: Father: Heart Disease High Blood Pressure Stroke Diabetes Cancer: Sibling(s): Heart Disease High Blood Pressure Stroke Diabetes Cancer: Other Family Member: Heart Disease High Blood Pressure Stroke Diabetes Cancer: Other: Do you have a living will or advanced directive? Do we have a copy? Does someone else make medical decisions for you? Yes Yes Yes No No No

Do you have or recently experienced any of the following: General: Head: fever chills vision problems poor teeth fatigue weight gain weight loss hearing problems gum disease Hematologic: bleeding disorder cancer anemia easy bruising/bleeding Coumadin use: Who follows PT/INR ---------- Last Time Checked: ------------ Pulmonary: asthma cough lung cancer blood in sputum emphysema pneumonia shortness of breath history of TB Cardiac: palpitations feet/leg swelling passing out Raynaud' s Gastro: loss of appetite nausea/vomiting constipation indigestion/reflux stomach ulcers painful swallowing liver problems/jaundice loose stools Vascular: blue lips/fingers clots in leg veins carotid disease Genitourinary: Extremities: painful urination blood in urine swelling arthritis prostate trouble urine infections increased frequency/hesitancy pain in legs cramps Musculoskeletal: muscles aches knee problems back pain joint pain disc problems Neurologic: stroke dizziness loss of balance numbness Alzheimers weakness poor weakness Skin: Endocrine: Psychiatric: Other: skin rash change in texture thyroid problems low blood sugar depression anxiety prior phen fen use

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