USF DEPARTMENT OF CARDIOLOGY NEW PATIENT INTAKE FORM

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1 Personal Data Name: Date: Date of Birth: Age: Occupation: Marital Status: Single Married Divorced Widowed Birth Place: Education Level: Reason for Cardiac Referral: Physician referring for Cardiac assessment: Have you seen a Cardiologist (heart doctor) before? Yes No If so, please ask them to fax your records our office or bring records with you. Do you have a pacemaker or other cardiac device? Yes No What brand? (Medtronic/St Jude/Guidant/Boston Scientific) Please bring card to appointment. Have you had any cardiac surgery or procedure (ablation, etc.)? Yes No What type of procedure and when? Patient s Social History Do you work? Yes No Retired- If yes, what do you do? Do you currently use or have previously used illicit drugs? Yes No If yes, how much, what type and how often? Do you currently use or have previously used (smoke or chew) tobacco? Yes No Cigarettes Yes No Pack per day for years. Date stopped Cigars Yes No Pack per day for years. Date stopped Pipe Yes No Pack per day for years. Date stopped Chewing Yes No Pack per day for years. Date stopped Snuff Yes No Pack per day for years. Date stopped Do your now or have you ever consumed alcohol? Yes No If yes, how much and how often? Do you now or have you ever consumed caffeine? Yes No If yes, how much and how often? Current diet/special diet? Exercise Yes No Duration and Frequency? How many blocks can you walk at a regular pace without stopping? What makes you stop? How many flights of stairs can you go up without stopping? Page 1 of 6

2 REVIEW OF SYMPTOMS Are you currently having or have you had the following problems? Anemia Yes No When? Anxiety Yes No When? Arthritis Yes No When? Attempted Suicide Yes No When? Black and Tarry Stools Yes No When? Blood in Stool Yes No When? Blood clots in legs/lungs Yes No When? Blood in Urine Yes No When? Blood Transfusions Yes No When? Chronic Bronchitis Yes No When? Runny or Stuffed Nose Yes No When? Depression Yes No When? Change in Bowel Habits Yes No When? Difficulty Hearing Yes No When? Exposure to Asbestos Yes No When? Corrective lenses? Yes No When? Eye Pain, Vision Problems/Spots, Blurriness? Yes No When? Esophageal Reflux Yes No When? Excessive Bleeding Yes No When? Gallbladder Disease Yes No When? Headache Yes No When? Dizziness (Syncope or fainting) Yes No When? Indigestion or Heartburn Yes No When? Frequent and/or productive cough Yes No When? Weight change Yes No When? Nervousness Yes No When? Chest pain, discomfort or pressure Yes No When? Back pain that radiates around to chest Yes No When? Palpitations Yes No When? Fatigue / Feeling tired Yes No When? Difficulty in breathing/shortness of breath Yes No When? Leg pain w/excertion (leg claudication) Yes No When? Awakening at night with shortness of breath Yes No When? Excessive sweating Yes No When? Abdominal pain Yes No When? Fever(s) Yes No When? Chills Yes No When? Vomiting Yes No When? Neck pain Yes No When? Jaw pain Yes No When? Excessive urination Yes No When? Sleep w/ extra pillows or sleeping upright Yes No When? Numbness or tingling in extremities Yes No When? Fast heart rate Yes No When? Slow heart rate Yes No When? Irregular heart rate Yes No When? Wheezing Yes No When? Swelling in legs, hands and/or feet Yes No When? Rapid breathing Yes No When? Coldness in hands and/or feet Yes No When? Hemorrhoids Yes No When? High Triglycerides Yes No When? HIV Yes No When? Hoarseness or Voice Change Yes No When? Page 2 of 6

3 Indigestion/ Heartburn Yes No When? Joint stiffness, Pain or Swelling Yes No When? Kidney Stones Yes No When? Loss of Appetite Yes No When? Nausea or Vomiting Yes No When? Nervousness Yes No When? Night Sweats Yes No When? Need to Get Out of Bed to Urinate? Yes No When? Pain in Legs While Walking Yes No When? Painful Urination Yes No When? Pneumonia Yes No When? Previous Mental Illness Yes No When? Renal Failure/Iodine Allergies Yes No When? Rheumatic Fever Yes No When? Ringing in Ears Yes No When? Seizures Yes No When? Severe Nose Bleeds Yes No When? Shortness of Breath W/Exertion Yes No When? Shortness of Breath Laying Flat in bed Yes No When? Sinus Problems Yes No When? Spells of Unconsciousness Yes No When? Stomach Ulcers Yes No When? Stroke Yes No When? Swelling of the Legs/Ankles Yes No When? Syncope (fainting spells) Yes No When? Thirst or Frequent Urination Yes No When? Thyroid Disease Yes No When? Tuberculosis Yes No When? Urinary Tract Infections When? Weight Change Yes No When? Wheezing Yes No When? Yellow Jaundice or Liver Disease Yes No When? Migraine headaches Yes No When? Family History Has anyone in your family (mother, father or sibling) had a heart attack? Yes No If yes, how old were they when it occurred? Has anyone in your family (mother, father or sibling) had sudden cardiac death or died at a young age inexplicably? Yes No Mother: If living, current age If deceased, age at death: History of heart disease: Yes No Cause of death: If yes, what age diagnosed? Diabetes High Cholesterol Hypertension Coronary Artery Disease Cardiomyopathy Arrhythmias Heart Failure Overall health of mother: Page 3 of 6

4 Father: If living, current age If deceased, age at death: History of heart disease: Yes No Cause of death: If yes, what age diagnosed? Diabetes High Cholesterol Hypertension Coronary Artery Disease Cardiomyopathy Arrhythmias Heart Failure Overall health of father: Siblings: PAST MEDICAL HISTORY Cardiac Do you currently have or have ever had any of the following diseases? Rheumatic Fever Yes No When diagnosed? Heart Murmur Yes No When diagnosed? Heart Attack (MI) Yes No When diagnosed? High Cholesterol Yes No When diagnosed? High Blood Pressure Yes No When diagnosed? Diabetes Yes No When diagnosed? Irregular Heart Beat Yes No When diagnosed? Palpitations Yes No When diagnosed? Congenital Heart Disease Yes No When diagnosed? Valvular Heart Disease Yes No When diagnosed? Enlarged Heart Yes No When diagnosed? Cardiomyopathy Yes No When diagnosed? Congestive Heart Failure Yes No When diagnosed? Coronary Artery Disease Yes No When diagnosed? Peripheral Vascular Disease Yes No When diagnosed? Page 4 of 6

5 PAST MEDICAL HISTORY - OTHER COPD Yes No When diagnosed? Asthma Yes No When diagnosed? Emphysema Yes No When diagnosed? Kidney Disease Yes No When diagnosed? Liver Disease Yes No When diagnosed? Cancer Yes No When diagnosed? What type? Bleeding Disorders Yes No When diagnosed? Stroke (CVA or ICH) Yes No When diagnosed? Thyroid disorders (hyper, hypo) Yes No When diagnosed? Other major medical problems? Have you ever had the following tests performed? If you have, please bring a copy of the results with you. Heart Catheterization Yes No When/Where? 12 Lead EKG Yes No When/Where? Holter Monitor Yes No When/Where? Event Monitor Yes No When/Where? Nuclear Stress Test Yes No When/Where? Treadmill Stress Test Yes No When/Where? Echocardiogram Yes No When/Where? Dobutamine Stress Test Yes No When/Where? Adenosine Stress Test Yes No When/Where? CT/MRI Yes No When/Where? Vascular Ultrasound Yes No When/Where? Cardiac Device Adjustment Yes No When/Where? Surgical History Previous surgeries: Type Place When Medications (taken regularly, including over the counter medications, vitamins, herbal supplements) Please bring all of your medications with you. Page 5 of 6

6 Name Dosage Frequency (How often) Allergies Medication or other Reaction? When diagnosed? Major Hospitalizations Reason for Admission Where? When? Patient Signature Date Physician Signature Date Page 6 of 6

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