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Name: _____________________________________________ Date: __________________ Referring MD: ________________________________ DOB: ____________ Age: ______ PCP: ________________________Other MDs you see: ____________________________ What is the primary reason you have come to Northwest Cardiovascular Center? Are you having or have you ever had? (check all for which the answer is yes) | [__] Increasing breathlessness with your usual activities | | [__] Shortness of breath at rest, lying down | [__] Recent cough | | [__] Heart attack | [__] Spells of rapid heartbeat | | [__] Pain, pressure / discomfort in the chest | [__] Palpitations | | [__] Any neck, jaw, left arm discomfort | [__] Passed (ing) out - fainting | | [__] Unexplained weight gain of more than 5 lbs.
in the last weeks or months. | [__] Dizzy spells | | [__] Worsening fatigue | [__] Pain or cramps in leg(s) with walking | | [__] Swelling of the ankles | [__] A stroke or temporary stroke | | [__] Abnormal EKG | [__] Heart murmur | | [__] Have you been hospitalized for your heart or what they thought was your heart? | [__] Rheumatic fever | | [__] Any other cardiac diagnosis? |
| | [__] Any tests or surgeries done for your heart? | What tests?_____________________________ | | [__] When and where were they done? _________________________________________ | Have you ever been diagnosed with? | High blood pressure | [__] Yes | [__] No | How long ago? ____________________ | | Diabetes | [__] Yes | [__] No | How long ago? ____________________ | | High cholesterol | [__] Yes | [__] No |
| What medications do you take for this, if any _______________________________________________________________________ | Lung disease | [__] Yes | [__] No | What type? _______________________ | | When? ___________________________ | | Blood vessel disease | [__] Yes | [__] No |
| | Which vessels? ____________________ When? ___________________________ | Is there any family history of: | [__] Heart attack | [__] Sudden death | | [__] Bypass surgery | [__] Hypertension | | [__] Angina Diabetes | [__] Clogged Arteries | Have you ever smoked? [__] Yes [__] No How may cigarettes per day? _______________
How long (have) did you smoke(d)? _________
If you quit, when did you quit? _____________ How many glasses per week do you consume of: Wine ____________ Beer ______________ Cocktails _________________ Where were you born? ___________________________________________ What do/did you do for work? __________________________________________ Do you get regular exercise? [__] Yes [__] No What kind? _________________________ Marital Status: [__] Single [__] Married [__] Divorced [__] Widowed List other medical problems you have had. These would include problems for which you have taken medications or been hospitalized. Please include the dates these problems occurred.
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______________________________________________________________________ List all surgeries you have had and when and where they occurred: | Surgery | When | Hospital | Surgery | When | Hospital | _______________________________________________________________________
_______________________________________________________________________ _______________________________________________________________________ Please list all of your medications, include non-prescription drugs, dietary supplements and vitamins. | Name of drug | Dose | How many times each day | ______________________ _________________ _________________________________
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______________________ _________________ _________________________________ Are you allergic to any medications? [__] Yes [__] No List those medications
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_________________________________________________________________________ Are you allergic to X-ray dye? [__] Yes [__] No Other Allergies? ____________________________________________________________ IS THERE ANY OTHER PROBLEM YOU WISH TO ADDRESS AT THIS VISIT?
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