Patient Information

Patient Name:
Today's Date:
Referring Physician:
Family Physician:
Date of Birth:		Age:
Social Security # :
Height:	ft. in.
Weight:
Gender:	female male
Marital Status:	single married widowed divorced
Number of Children:

Personal Health History

What is the reason for this visit?

Have you ever had a heart problem?   Yes No

If yes, please explain:

Do you have or have you ever had any of the following?

Rheumatic Fever  Date:		Heart Murmur   Date:
Heart Attack  Date:		Chest Pain/Pressure   Date:
Heart Failure  Date:		Rapid Heart Beat or irregular pulse   Date:
Light Headedness  Date:		Dizziness   Date:
Fainting  Date:		Swelling of the ankles   Date:
Congestive Heart Failure  Date:		Pain in calf muscles when walking   Date:
Shortness of breath  Date:

Have you ever had any of the following heart studies?

EKG	Echocardiogram	24 Hour monitor
Cardiac Catheterization	Treadmill	Chest x-ray

Other:

Have you ever had a reaction to the dye used in certain cardiac x-rays? Yes  No  I have never had this type of x-ray

Do you have any allergies to medication?  Yes  No If yes, please list all of the medications:

Do you currently smoke?  Yes  No Packs per day:   Number of Years: Have you ever smoked?  Yes  No Date Stopped: Do you have Elevated Cholesterol?   Yes  No  Not sure Last checked: Do you have High Blood Pressure?   Yes  No  Not sure How many years: Do you drink alcoholic beverages?   Yes  No  Not sure How much each day: Are you generally stressed?   Yes  No  Not sure Do you drink beverages containing caffiene?   Yes  No  Not sure How much: Do you excercise?  Yes  No If yes, what is your exercise routine? Are you following a special diet?  Yes  No If yes, please described: Occupation:   Describe your job task: Are you retired?   Yes  No Date retried: Are you disabled?  Yes  No If yes, please described:

Describe any surgeries you have had?

Surgery	Year

Please check any other health condition you have or have had in the past:

Scarlet Fever		Menstrual Dysfunction
Anxiety		Kidney Disease
Emphysema		Breathing Problems
Ulcer		Venereal Disease
Anemia		Sexual Dysfunction
Arthritis		Asthma
Stomach or Bowel Disorder		Allergies/Hay Fever
Fatigue		Gout
Urinary		Thyroid Disease
Rheumatic Fever		Diabetes/High Blood Sugar
Depression		Migrane Headache
Constipation		Liver Disease
Cancer:		Other:

Do you have a history of heart disease in your family?   Yes   No If yes, indicate relationship and age problems started:

Family Member(s)	Alive	Deceased	Current Age or Age at Death	Cause of Death
Mother
Father
Sister(s)
Brother