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NEW PATIENT QUESTIONNAIRE
You have the option to either submit the form digitally, or download it to fill out manually.
Step 1 of 7
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Name
First
Last
Male
Female
Phone
Email
Date
Weight
Height
Have you ever had any medical problems?
Yes
No
Please select any condition that may apply
Heart Attack
Stroke
High Blood Pressure
Cancer
Asthma
Diabetes
Ulcers
Vascular Disease
Rheumatic Fever
Mitral Valve Prolapse
Hepatitis
Thyroid Disease
Kidney Disease
Endocarditis
Emphysema
Hiatal Hernia
Gallbladder
Elevated Cholesterol
Sleep Apnea
Atrial Fibrillation
Date Heart Attack Date
Stroke Date
High Blood Pressure Date
Cancer Date
Asthma Date
Diabetes Date
Ulcers Date
Vascular Disease Date
Rheumatic Fever Date
Mitral Valve Prolapse Date
Hepatitis Date
Thyroid Disease Date
Rheumatic Fever Date
Kidney Disease Date
Endocarditis Date
Emphysema Date
Hiatal Hernia Date
Gallbladder Date
Elevated Cholesterol Date
Sleep Apnea Date
Atrial Fibrillation Date
Have you had any previous surgical procedures?
Yes
No
Please list any sugical procedures along with the date.
Have you ever had a cardiac catherization, angioplasty, stress test, or treadmill study?
Yes
No
When and where did you have your study?
Are you currently taking any medications?
Yes
No
Please list all medications you are presently taking, along with dosage (strength), and frequency (number of times per day)
Are you taking any over-the counter medications?
Yes
No
(Example: decongestants, diet pills. pain pills, or antihistamines.)
Please list all over-the-counter medications you are presently taking.
Are you allergic to any medications?
Yes
No
Please list the medication and the type of reaction.
Have you ever smoked?
Yes
No
How many years? How many packs per day? When did you quit?
Do you consume alcoholic beverages?
Yes
No
How many drinks per day?
Do you consume caffeine?
Yes
No
How many cups of coffee do you drink per day?
Have you ever used any recreational drugs?
Yes
No
what type?
Do you have a family history of heart disease?
Yes
No
Please list which family member, type of heart disease and age at the time of diagnosis.
What is your occupation?
Have you ever experience the following symptom(s)?
Fever or shaking chills
Unexplained weight loss or weight gain
Passed out
Migraines or frequent headaches
Difficulty swallowing
Nosebleeds
Vertigo (severe dizziness)
Chronic coughing or wheezing
Shortness of breath?
Coughed up blood
Experienced chest pain or chest tightness
Feet and ankle swell
Palpitations (skipping or racing heartbeat)
Problems with constipation
Problems with diarrhea
Passed black, tarry bowel movement
Difficulty in urinating
Pain or burning upon urination
Blood in your urine
Arthritis
Seizures or tremors
Rashes related to medication
Ulcers on your feet
Unusual anxiety or stress
Date of last menstrual period?
Who is your family doctor?
What pharmacy do you use? Please provide your pharmacy phone number.
List any other physicians you see.
Have you had any procedures, x-rays or blood work done recently?
Yes
No
If you answered yes to having any procedures, x-rays or blood work done recently, please state the name of test and where performed.
What is the purpose of your visit?
Pre-operative evaluation?
New patient visit?
Hospital follow-up?
Other
Purpose of visitor: Other
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