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Click here to download New Patient Health Questionnaire

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Fill-up New Patient Health Questionnaire online below:

  • Please do note that our average time for a new patient appointment is 2-3 hours.
  • 2. Have you had any heart disease and/or prior testing?

  • 3. Which of these risk factors for heart disease do you have?

  • 4. Do you have any blood vessels diseases?

  • 5. Do you have dizziness/lightheadedness/syncope (passing out)?

    If yes, describe in your own words each spell or last three spells.
  • 6. Do you have palpitations?

  • 7. What is your Past Surgical History(Operations)?

    (Do not re-list any cardiac operations already listed)
  • Example - Procedure: Appendectomy
    Year: 1995
    Location: Medical City of Dallas
  • 8. What are your current Medications?

    (Please list all your prescription medications, non-prescription medications, vitamins, and over the counter medication including aspirin.)
  • NAME I DOSAGE/STRENGTH | FREQUENCY
    Example - Lasix I 40 mg I 2 tabs am / 1 tab pm
    (If no, skip to the next section)
  • Please list all medications to which you have an allergy to or adverse response to and list the reaction.
    MEDICATION I REACTION
    Example - Penicillin I Arm Rash
  • 10. What is your medical history?

  • 11. What is your social history?

  • 12. What is your family history?

    (Please fill out details of your biological relatives only)
  • Father

  • Mother

  • Brother(s)

  • Sister(s)

  • Son(s)

  • Daughter(s)

  • 13. Recent Hospitalizations

  • 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)
  • Use the scale below to complete the list regarding your symptoms and their frequencies
    • O = Never
    • 1 = 1 time a month
    • 2 = 2-4 times a month
    • 3 = 5-7 times a month
    • 4 - Daily
  • 15. Review of Systems:

    (Check all that apply)