Patient Forms

Click here to download Auth Release Records From Us

Click here to download Patient Information

Click here to download New Patient Health Questionnaire

Click here to download Auth Release Records To Us

Click here to download Patient Portal

Click here to download HBC Telemedicine Informed Consent Form

Click here to download Telemedicine Quick Reference Sheet for Patients

Click here to view How to do Televisits

Click here to view how to do to Televisits using Mobile App

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.)
    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.
    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)