Patient History - Interventional Cardiology
NAME: ________________________________________________ DATE: _______________GENERAL HEALTHFatigueFever/shaking chillsLoss of appetiteLoss of weightJoint stiffnessSKINPsoriasisHair LossRashEasy BruisingShinglesCARDIOVASCULARHigh Blood PressureAnginaHeart AttackStrokeHeart MurmurPalpitationsRheumatic FeverShortness of BreathPULMONARYAsthmaPneumonia/BronchitisEmphysemaTuberculosisMETABOLIC DISEASESDiabetesThyroidElevated CholesterolElevated TriglyceridesGASTROINTESTINALUlcersHiatus HerniaDiverticulosisColitisHepatitisJaundiceGall BladderURINARY TRACTKidney InfectionsBladder InfectionsKidney StonesBlood in UrineNEUROLOGIC-PSYCHIATRICSeizuresNeuropathyMuscle PainMuscle WeaknessHEAD & NECKHeadachesGlaucomaCataractsDry Eyes/MouthBLOOD DISORDERSAnemiaLow White CountLow Platelet CountBleeding ProblemsEXTREMITIESPhlebitisVaricose VeinsLeg Cramps/nightLeg Cramps/walkingSMOKING HISTORYPast_______Yr Quit _______ # of packs _______ # of yearsPresent _______ # of packs _______ # of yearsALCOHOLPresentPastSURGERIES/OPERATIONSYEAR________TYPE_________________YEAR________TYPE_________________YEAR________TYPE_________________OTHER HOSPITALIZATIONSYEAR________TYPE_________________YEAR________TYPE_________________YEAR________TYPE_________________FAMILY HISTORYSpecify Disease:Father: _____________________________Mother: ____________________________Siblings: ____________________________Other: ________________________________________________________________Physician Signature__________________PROCEDURESCatheterization__________Date_________Echocardiogram_________Date_________Stress Test_____________Date_________MEDICATIONS_______________________________________________________________________________________________________________________________________________________________________________ALLERGIES____________________________________________________________________________________________________________________________________________ ................
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