Cardiovascular Genetics Clinic Arrhythmia Questionnaire

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Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Primary Care Physician: Why have you been referred for a Cardiovascular Genetics Appointment? Have you had a genetics evaluation? If so, explain: Have you had any genetic testing? If so, what were the results? Who is your referring physician? What is your race or ethnic background? If you are multi-racial, check all that apply: White Black Hispanic Asian E. Indian French Canadian Mediterranean/Greek/Italian Native American Indian Multi-racial Other: Adopted Ashkenazi Jewish descent What country is your mother s family from? What country is your father s family from? What is the highest level of education you completed? Elementary school Middle school High school Some college College degree Graduate/Professional degree What is your occupation? Your current height Your current weight Page 1 of 5

Surgical History Type of Surgery Date Physician & Location Imaging History Type of Imaging (CT, MRI, Echocardiogram ) Date Physician & Location Result of Study Page 2 of 5

Medical History Questionnaire Do you or your family members have a history of any of the following? High Blood Pressure High Cholesterol Diabetes Stroke Learning Problems Other neurologic problems (seizures, migraines) Hearing Loss Cardiac Arrest Coronary artery disease or heart attack Pacemaker or ICD Vascular or blood vessel problems Arrhythmia disorder? (Long QT, SQT, CPVT, Brugada, ARVD) Fainting or passing out? Bypass Surgery Heart Transplant Muscle Disease/Weakness Cancer (indicate type) Lung Problems (ex: collapsed lung, pneumothorax) Other major medical conditions Miscarriages or sudden infant death? Do you smoke? Have you ever smoked? Do you use drugs? Do you drink alcohol? Self Family Member (who?) Explain Page 3 of 5

Your Family Tree Mother s Age: (now or age deceased) Father s Age: (now or age deceased) Total Indicate half siblings Ages Total Indicate half siblings Ages How many sisters How many brothers How many daughters How many sons do you have? How many maternal aunts How many maternal uncles How many paternal aunts How many paternal uncles Has anyone in your family had genetic testing? Yes No If yes, what were the results? (If yes, please bring a copy of your family member s test result to your appointment.) Page 4 of 5

Review of Systems Are you experiencing or have you ever experienced any of the below? Please check the appropriate box(es). General: Eyes: Ears: Nose/Mouth/Throat: Respiratory: Cardiovascular: Hematology/ Lymphatic: Gastrointestinal: Musculoskeletal: Renal/Urinary: Neurological: Psychological: Endocrine: Integument: Allergy/ Immunology: Fatigue Fever Chills Recent weight change Blindness Glasses Vision problems Eye Surgery Hearing impaired/deaf Frequent ear infections Tinnitus (ringing) Vertigo (dizziness/feeling of motion) Anosmia Dental problems Difficulty swallowing Epistaxis (nose bleeds) Asthma Cough Frequent pneumonias Dyspnea (shortness of breath) Murmur Syncope (fainting) Cyanosis (blue) Edema (swelling) Easy bleeding Transfusions Anemia Nausea or Vomiting Bloody stools Jaundice Heartburn or Indigestion Joint laxity Joint pain or stiffness Fractures Limb abnormalities Dysuria (painful urination) Incontinence Frequent UTIs Hematuria (blood in urine) Kidney stones Seizures Headache Gait abnormalities Numbness or Tingling Memory loss Anxiety Bipolar Disorder Depression ADHD Schizophrenia Thyroid problems Polydipsia (thirst) Polyphagia (hunger) Heat or cold intolerance Hirsutism (excess hair) Birthmarks Rashes Hypo- or Hyperpigmented macules Keloids Drug allergies Allergies to other substances Seasonal allergies Immune problems Page 5 of 5

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