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Open : 8am - 5pm (Mon - Fri)
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
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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
0323 - ROS
Name:
(Required)
Appointment Date:
(Required)
MM slash DD slash YYYY
Respiratory
Asthma
Yes
No
Emphysema/COPD
Yes
No
Recent or current smoker
Yes
No
Shortness of breath - exertion
Yes
No
Shortness of breath - lying flat
Yes
No
Persistent cough
Yes
No
Cardiovascular
High cholesterol
Yes
No
Congestive heart failure
Yes
No
Swollen extremities
Yes
No
History of stroke/TIA
Yes
No
Sensation of rapid heartbeat
Yes
No
Sensation of slow heartbeat
Yes
No
History of heart attack
Yes
No
Chest pain/discomfort
Yes
No
Diagnosis with POTS
Yes
No
Constitutional
Weight gain
Yes
No
Weight loss
Yes
No
Obesity
Yes
No
Problem losing weight
Yes
No
Problem gaining weight
Yes
No
Endocrine
Excessive sweating during day
Yes
No
Excessive sweating at night
Yes
No
Itching of hands or feet
Yes
No
Low thyroid
Yes
No
High blood pressure
Yes
No
Diabetes
Yes
No
Low blood pressure
Yes
No
Gastrointestinal
Bloating after meals
Yes
No
Diarrhea
Yes
No
Loss of appetite
Yes
No
Excessive thirst
Yes
No
Increased appetite
Yes
No
Constipation
Yes
No
Heartburn
Yes
No
Nausea/Vomiting
Yes
No
Difficultly swallowing/choked
Yes
No
Saliva dropped out of mouth
Yes
No
Diagnosis with Gastroparesis
Yes
No
Abdominal Pain
Yes
No
Hematologic
Anemic
Yes
No
Bleeding while brushing teeth
Yes
No
On blood thinners
Yes
No
Nosebleeds
Yes
No
Bruising
Yes
No
Pro-longed bleeding
Yes
No
Musculoskeletal
Pain in legs
Yes
No
Poor leg circulation
Yes
No
Arthritis
Yes
No
Leg cramps
Yes
No
Muscle weakness/aches
Yes
No
Diagnosis with EDS
Yes
No
Neurologic
Fainted in the last 6 months
Yes
No
Dizziness/lightheadedness
Yes
No
Lightheadedness with standing
Yes
No
Confusion/Impaired memory
Yes
No
Impaired memory on standing
Yes
No
Slurred speech
Yes
No
Feeling of vertigo
Yes
No
Headache/head pounding
Yes
No
Seizures
Yes
No
Tremors
Yes
No
Trouble tolerating cold
Yes
No
Trouble tolerating heat
Yes
No
Ophthalmologic
Cataracts/Glaucoma
Yes
No
Sensitive to light
Yes
No
Seeing double
Yes
No
Blurry vision
Yes
No
Blurry vision with standing
Yes
No
Psychology
Depression
Yes
No
Irritability/impatient
Yes
No
Sleep apnea
Yes
No
Snoring
Yes
No
Trouble concentrating
Yes
No
Currently using a CPAP/BiPAP
Yes
No
Fatigue/feeling weak
Yes
No
Anxiety
Yes
No
Always tired during the day
Yes
No
Falls asleep during inappropriate times
Yes
No
Frequent wakening at night
Yes
No
Overall restless sleep
Yes
No
Difficultly maintaining sleep
Yes
No
Stop breathing at night
Yes
No
Urologic
Difficult starting to urinate
Yes
No
Frequent urination
Yes
No
Urinary leaking
Yes
No
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Last Name
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