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Name
DOB
Date
(mmddyyyy)
Referring Physician
Other Physician
Describe the present problem that brings you to our office. (Please be specific with symptoms.)
DRUG ALLERGIES & INTOLERANCES
MEDICATIONS (Including Over-the-Counter Medications)
Name
Dose
Frequency
Name
Dose
Frequency
MEDICAL HISTORY (Check all that apply.)
High Blood Pressure
Valve Disease
Glaucoma
Ulcers
Stroke
Coronary Artery Disease
Heart Failure
Dialysis
Hiatal Hernia
Gout
Atrial Fibrillation
Asthma
Cancer
TIA
Arthritis
Heart Attack
Emphysema
Diabetes
HIV/AIDS
Latex Allergy
OTHER ILLNESSES
YEAR
SURGERIES & PROCEDURES
YEAR
PRIOR CARDIAC TESTING
List all Exercise Tests, Heart Catheterizations (Coronary Angiograms) and Echocardiograms (Ultrasounds) you have had.
Type of Test
Date
Location
RISK FACTORS
(Check / answer all that apply.)
High Blood Pressure
High Cholesterol
Tobacco Use
Packs / Day
Years
Quit Smoking
Cigarettes
Pipe
Cigars
Chew
Diabetes
Peripheral Vascular Disease
SOCIAL HISTORY
(Check / answer all that apply.)
Illicit Drug?
Amount / Day
Special Diet
Alcohol?
Amount / Day
Are you retired?
Coffee?
Amount / Day
Occupation
Marital Status
Married
Single
Divorced
Widow(er)
FAMILY HISTORY
(Check / answer all that apply.)
LIVING?
Describe Heart / Circulatory Problems
Father
Mother
Brother(s)
Sister(s)
Additional Family History
SIGNIFICANT CHILDHOOD ILLNESSES
(Check any you have had.)
Rheumatic Fever
Hepatitis
Tuberculosis
Yellow Jaundice
Other
REVIEW OF SYSTEMS
CARDIAC
RESPIRATORY
Chest Pain
Shortness of Breath
Cardiac Arrest
Cough/Sputum/Phlegm
Heart Rythm Problem
Wheezing
Fainting or Blackouts
Chronic Lung Disease
Heart Murmur
HEENT
Swelling
Serious Eye Problems
Leg/Buttock Pain
Hearing Problems
CONSTITUTIONAL
Nose Problems
Trouble Sleeping
Throat Problems
Lack of Energy
HEMATOLOGIC
Appetite Changes
Bleeding Disorders
Weight Changes
Anemia
Thyroid Problems
Blood Clots
Fevers/Frequent Infections
GENITO-URINARY
GASTROINTESTINAL
Recurrent Urinary Tract Infection
Liver Problems
Frequent Urination at Night
Nausea/Vomiting
Difficult Urination
Heartburn
Menopause
Constipation
Prostate Problems
Blood in Stool
Blood in Urine
Diarrhea
Kidney Stones
Swallowing Difficulties
Pregnancy
Abdominal Pain
Loss of Bladder Control
MUSCULOSKELETAL
Kidney Problems
Difficulty Walking
NEUROLOGICAL
Joint Pain/Swelling
Numbness/Tingling
Back Pain
Dizziness
SKIN
Weakness
Non-Healing Sores
Seizures
PSYCHOLOGICAL
Depression/Anxiety
