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Surgeon: Argenziano aka Williams Takayama Smith Stewart ew ork Presbyterian Hospital Cardiothoracic Surgery Patient History Form M Date our information is important to us, Please PIT Clearly 0 0 0 3 1 Please Mark Ovals with: X ast ame Middle Initial First ame Street Address Apt. City State Zip Code Home Phone Work Phone Email Occupation Age Height ' " Weight lbs Sex M F @ M F Marital Status S M D W Cardiologist eferring Physician eason for Visit epair of Congenital Defect Aneurysm epair Valve Surgery Diagnostic Evaluation Bypass Surgery Other Allergies Penicillin Contrast Dye Shellfish Sulfa atex Iodine o known drug or latex allergies Smoking/Alcohol Use Do you currently use tobacco? Did you quit smoking? If es, How Many Packs Per # ears Smoked ear - - Packs Per # ears Smoked Current Drug use? Describe Alcohol use? arely umber Drinks/ umber Drinks/ Week Current Vitamins/Supplements Folic Acid Iron Multi-Vitamin Vitamin E

Print umbers in the boxes. For Example: Medications exium Atenolol (opressor) Toprol X (metoprolol) Diovan (valsartan) ipitor (atorvastatin) 20 40 80 160 25 50 50 100 20 40 0 1 2 3 4 5 6 7 8 9 Dosage per Tablet Times/ 0 0 0 3 2 Hydrocholorothiazide (HCTZ) anoxin (digoxin) furosemide (asix) 25 0.125 0.25 40 80 Potassium Aspirin (Ecotrin) 10 meq 20 meq 81 325 meq Plavix (clopidogrel) 75 Coumadin (warfarin) Mon Tue Wed Thur Fri Sat Sun Insulin 1. With Meals Or AM units PM units As eeded Units Insulin 2. Please ist our Other Medications here Dosage Per Tablet Times/

Please enter dates using the following format: Past Medications Please list any medications you have stopped taking during the past year: ear 0 1 0 1 0 7 0 0 0 3 3 1. 2. 3. 4. Please mark X next to any of the following tests or procedures you have had: ear Where did you have the test/procedure? Echocardiogram Stress Test Cardiac Catheterization Previous Heart Surgery Angioplasty Stenting Pacemaker Defibrillator (AICD) Make Model Date of last generator change: ear ist All Other Surgeries and Dates Here ear

Please enter dates using the following format: ear 0 1 0 1 0 7 0 0 0 3 4 Date of First Occurence Heart Murmur ear Endocarditis heumatic Fever Irregular Heart hythm High Blood Pressure Elevated Cholesterol Heart Attack Congestive Heart Failure (CHF) Abnormal EKG Ankle Swelling Chest Pain if yes, at rest w/ exercise while asleep Shortness of Breath if yes, at rest w/ exercise while asleep History of problems with your ungs Chronic Cough Abnormal Chest X-ay Bronchitis Use Inhalers Emphysema Asthma Currently Take Steroids Took Steroids in past ast Used ear Pneumonia Pulmonary Function Tests? When COPD Where did you have the test? ung Cancer

Please Mark Ovals with: X 0 0 0 3 5 History of problems with your Arteries/Veins/Circulation Easy Bruising Problems with your blood/clotting eg Cramps w/ Walking Sickle Cell Anemia Bleeding Tendency ear Previous Transfusion eg Varicose Veins Vein Stripping ear Heart Surgery w/ eg Vein Harvest History of problems with your Kidneys/Bladder/Prostate Frequent Urination Prostate Disease Difficulty Urinating Kidney Stones Frequent Urinary Tract Infections Kidney Disease Dialysis How often? M T W Th F Sa Su Surgery on: ear Prostate Bladder

Ulcers Please Mark Ovals with: History of problems with your iver/gi System/Stomach Jaundice X 0 0 0 3 6 Bleeding Ulcers Blood in Stool Pancreatitis Hepatitis A B C ear History of problems with your eurological/musculoskeletal system Arthritis Fainting Muscle Weakness eck/back Injury Seizures Stroke Date ear Describe eck/back Injury Other Medical History Glasses oose/capped/missing/chipped Teeth Dentures or Bridges: emovable Permanent Contacts Cancer Type Glaucoma Hearing Problems Diabetes Date Diabetes diagnosed ear Gout Diabetes Controlled with: Thyroid Disease Diet Controlled Oral Meds Insulin Extreme Anxiety Psychiatric Illness

T H A K O U! 0 0 0 3 7 Family Medical History Mark if Diagnosed with Heart Age Disease Cause of Death Mother Father Brother(s) Sister(s) PEASE ADD A ADDITIOA MEDICA HISTO IFOMATIO BEOW

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