Please note that our average time per patient in the first visit is 2-3 hours. Step 1 of 15 6% Please do note that our average time for a new patient appointment is 2-3 hours.Date:* Patient Name:* BIRTHDATE Month Day Year 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?Do you have an implantable loop recorder? 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)Example - Procedure: Appendectomy Year: 1995 Location: Medical City of DallasProcedure: 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.)NAME I DOSAGE/STRENGTH | FREQUENCY Example - Lasix I 40 mg I 2 tabs am / 1 tab pm__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ __________________________________________ | __________________________________________ | __________________________________________ / __________________________________________ 9: Are you allergic to any medication? Yes No (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 1. 2. 3. 4. 5. 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) FatherIllness Living Yes No Age MotherIllness 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 HospitalizationsHave 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)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 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 Δ
