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Mckinney Office
Dallas Office
214-504-9942
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Services we offer
POTS Treament
Diagnostic Testing Services
Autonomic Nervous System Testing
Metabolic Stress Testing
Echocardiography
24-Hour Blood Pressure Monitoring
Assessment of Forearm Blood Flow
P Wave Signal Averaging
Carotid Doppler
Lipid Profile
EECP
Pulmonary Function Tests
Vascular Testing
Signal Average EKG
Stress Test
Thyroid Function Tests
Holter Monitor
Tilt Table Testing
About Us
About Dr. Suleman
Our Team
Heartbeat Clinic Journal
Start Televisit
Locations
McKinney
Dallas
Contact us
More
Patient Forms
Blogs
Home
Services we offer
POTS Treament
Diagnostic Testing Services
Autonomic Nervous System Testing
Metabolic Stress Testing
Echocardiography
24-Hour Blood Pressure Monitoring
Assessment of Forearm Blood Flow
P Wave Signal Averaging
Carotid Doppler
Lipid Profile
EECP
Pulmonary Function Tests
Vascular Testing
Signal Average EKG
Stress Test
Thyroid Function Tests
Holter Monitor
Tilt Table Testing
About Us
About Dr. Suleman
Our Team
Heartbeat Clinic Journal
Start Televisit
Locations
McKinney
Dallas
Contact us
More
Patient Forms
Blogs
Request An Appointment
New Patient Health Questionnaire
Please note that our average time per patient in the first visit is 2-3 hours.
Step
1
of
15
6%
Date:
*
Patient Name:
*
DOB:
Age:
Gender:
*
Male
Female
Primary Care Physician:
*
How did you find us?
Referring Physician
Friend
Internet
1. Please INDICATE all the reasons for your visit (Check all that apply)
Chest Pain
Shortness of Breath
Palpitations
Dizziness/Fainting
Blurry Vision
Hypertension
Hypotension
High Cholesterol
Heart Failure
Coronary Artery Disease
Swollen Extremities
Postural Orthostatic Tachycardia Syndrome
Pacemaker/Defibrillator Evaluations
Arrhythmia Evaluation
Possible Testing
Pre Surgical Evaluation
Establish New Cardiologist
2. Have you had any heart disease and/or prior testing?
Do you have a Heart Murmur/Valve Prolapse?
Yes
No
Have you ever had Rheumatic/Scarlet Fever?
Yes
No
Have you ever had a Heart Attack?
Yes
No
Have you ever had a Heart Cath/Angioplasty/Stent?
Yes
No
If yes, what year?
Have you ever had Bypass Surgery?
Yes
No
If yes, what year?
Do you have an implantable pacemaker/defibrillator?
Yes
No
Which Manufacture?
If yes, what year?
Have you ever had a Stress Test?
Yes
No
If yes, what year?
Have you ever had an Echocardiogram?
Yes
No
If yes, what year?
Have you ever had a Carotid Doppler?
Yes
No
If yes, what year?
Have you ever had a Holter Monitor (24 Heart Monitor)?
Yes
No
If yes, what year?
3. Which of these risk factors for heart disease do you have?
Have you ever had High Cholesterol?
Yes
No
Have you ever had High Blood Pressure?
Yes
No
What does your blood pressure usually run?
Are you a Diabetic?
Yes
No
If yes, what was you last HgA1C?
If you are a female, do you have Female Menopause?
Yes
No
Are you a Current or Recent Smoker?
Yes
No
If you have quit, what year?
Have you are taking Phen or Fen Weight Loss Medication?
Yes
No
4. Do you have any blood vessels diseases?
Do you have Carotid Disease or Endarterectomy?
Yes
No
When?
Have you ever had a Stroke or TIA (Mini-Stroke)?
Yes
No
When?
Do you have an Aortic Aneurysm?
Yes
No
When?
Do you have Poor Leg Circulation?
Yes
No
Do you have any Venous Thrombosis (Leg Clots)?
Yes
No
When?
Do you have any Pulmonary Embolism (Lung Clots)?
Yes
No
When?
5. Do you have dizziness/lightheadedness/syncope (passing out)?
Have you ever had a fainting or black out spell?
Yes
No
If yes, describe in your own words each spell or last three spells.
1st Spell
2nd Spell
3rd Spell
Were any of the above spells accompanied by (Check all that apply)
Nausea/Vomiting
Blurry Vision
Chest Pain
Fast/Irregular Heart Beat
Shortness of Breath
Head Ache/Pounding
Did they occur in a standing a position?
Did they occur in a sitting position?
Do you get Dizziness/Lightheaded when you stand up suddenly?
6. Do you have palpitations?
Do you ever have Palpitations (awareness of heart beat)?
Yes
No
If yes, how would you classify your palpitations? (Check all that apply)
Fast Heart Beat
Irregular Heart Beat
Normal Beats with Skipped or Extra Beats
Unknown
Other
What do you think makes your palpitations worsen? (Check all that apply)
Stress
Exercise
Sleep
After Eating
Other
7. What is your Past Surgical History(Operations)?
(Do not re-list any cardiac operations already listed)
Procedure:
Year:
Location:
Procedure:
Year:
Location:
Procedure:
Year
Location:
Procedure:
Year:
Location:
Procedure:
Year:
Location:
Procedure:
Year:
Location:
8. What are your current Medications?
(Please list all your prescription medications, non-prescription medications, vitamins, and over the counter medication including aspirin.)
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
9: Are you allergic to any medication?
Yes
No
(If no, skip to the next section)
1.
2.
3.
10. What is your medical history?
1. Have you ever had Hepatitis/Jaundice?
Yes
No
If yes, what year?
2. Do you have Asthma?
Yes
No
If yes, what year?
3. Have you ever had a Peptic Ulcer?
Yes
No
If yes, what year?
11. What is your social history?
Marital Status:
Occupation:
Hours a week you work?
Do you exercise?
Yes
No
How many hours per week?
Types of activity:
Do you ever drink alcohol?
Yes
No
Drinks per week?
Quit Year:
Do you smoke?
Yes
No
Quantity:
Quit Year:
Do you do illicit drugs:
Yes
No
Do you consume caffeine?
Yes
No
How much?
12. What is your family history?
(Please fill out details of your biological relatives only)
Father
Illness
Living
Yes
No
Age
Mother
Illness
Living
Yes
No
Age
Brother(s)
Illness
Living
Yes
No
Age
Sister(s)
Illness
Living
Yes
No
Age
Son(s)
Illness
Living
Yes
No
Age
Daughter(s)
Illness
Living
Yes
No
Age
Have any of your family members had a history of Heart attack, Angina, Coronary Bypass or Angioplasty under age 55-65?
Yes
No
Have any of your family members had a history of Stroke, under age 55 - 65?
Yes
No
Do you have any family history of Sudden Cardiac Arrest (Death)?
Yes
No
13. Recent Hospitalizations
Have you recently been hospitalized?
Yes
No
When?
Where?
If yes, Why?
14. Autonomic Nervous System Questionnaire
(The Autonomic Nervous System plays an important role in many arrhythmias and related symptoms to help us diagnosis your symptoms)
Fainting (Syncope)
0
1
2
3
4
Dizziness/Lightheadedness (Faintness)
0
1
2
3
4
Lightheadedness on standing
0
1
2
3
4
Impaired memory on standing
0
1
2
3
4
Impaired Memory/Confused
0
1
2
3
4
Sensation of Head/Room Spinning
0
1
2
3
4
Head Ache/Head Pounding
0
1
2
3
4
Tremulousness
0
1
2
3
4
Exertional Shortness of Breath
0
1
2
3
4
Shortness of Breath when lying down
0
1
2
3
4
Sensation of Rapid Heart Beat
0
1
2
3
4
Sensation of forceful, Slow Heart Beat
0
1
2
3
4
Chest Discomfort
0
1
2
3
4
Excessive Sweating during day
0
1
2
3
4
Excessive Sweating at night
0
1
2
3
4
Clamminess of Skin
0
1
2
3
4
Itching of Hands/Feet
0
1
2
3
4
Trouble tolerating cold
0
1
2
3
4
Trouble tolerating heat
0
1
2
3
4
Bloating After Meals
0
1
2
3
4
Nausea/Vomiting
0
1
2
3
4
Right Upper Abdominal Pain
0
1
2
3
4
Difficultly swallowing or choking
0
1
2
3
4
Saliva dribbling out of mouth
0
1
2
3
4
Has food ever been stuck in your throat
0
1
2
3
4
Abdominal discomfort
0
1
2
3
4
Constipation
0
1
2
3
4
Heartburn
0
1
2
3
4
Neck/Shoulder Aches
0
1
2
3
4
Muscle Aches
0
1
2
3
4
Joint Aches
0
1
2
3
4
Pain in legs
0
1
2
3
4
Leg cramps
0
1
2
3
4
Blurry vision on standing
0
1
2
3
4
Blurry/Dimming of Vision
0
1
2
3
4
Eyes sensitive to light
0
1
2
3
4
Fatigue/Feeling Weak
0
1
2
3
4
Trouble falling asleep
0
1
2
3
4
Difficulty maintaining sleep
0
1
2
3
4
Daytime fatigue
0
1
2
3
4
Anxiety
0
1
2
3
4
Urinary Incontinence/Leaking
0
1
2
3
4
Difficulty Emptying Bladder
0
1
2
3
4
Loose/Watery Stools
0
1
2
3
4
15. Review of Systems:
(Check all that apply)
Cancer (List Any)
Endocrine:
Low Thyroid
High Thyroid
Diabetes
Eyes:
Glaucoma
Cataracts
Lungs/Breathing:
Persistent Cough
Bronchitis
Emphysema
COPD
Pneumonia
Neurological:
Seizures/Epilepsy
Stroke
Abdomen:
Hiatus Hernia
Kidney/Bladder:
Renal Failure
Dialysis
Kidney Stones
Infections:
AIDS
HIV
Blood:
Bleeding Problems
Leukemia
First Name
Last Name
Email
Phone
Date of Birth
Patient Address
City
Zip Code
Reason For Contact
Other
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