Cardiology Princeton NJ | Princeton Interventional Cardiology



Princeton Interventional Cardiology, P.A.Office Visit Examination Page 1 of 3Patient Name:__________________________________Date: ______________Patient Date of Birth__________________________________Height ______________Your answers on this form will help your health care provider better understand your medical concerns and conditions better. This form will not be put directly into your medical chart. If you are uncomfortable with any question, do not answer it. Thank You.Main reason for today’s visit____________________________________________________________Other concerns you which to address during today’s examination_____________________________________________________HAVE YOU EXPERIENCED THE FOLLOWING SYMPTOMS SINCE YOUR LAST EXAMINATION?PLEASE CIRCLE YES OR NO TO THE FOLLOWING QUESTIONS:Chest pain/pressure/discomfortYesNoPalpitationsYesNoShortness of breath with exertionYesNoShortness of breath at restYesNoFoot, calf, buttock, hip or thigh discomfort (aching, tingling, cramping or pain) when you walk whichIs relieved by rest?YesNoDo you experience any pain at rest in your lower legs or feet?YesNoDo you experience foot or toe pain that often disturbs your sleep?YesNoAre your toes or feet pale, discolored or bluish?YesNoDo you have skin wounds or ulcers on your feet or toes that are slow to heal (8-12 weeks)?YesNoHas your doctor ever told you that you have diminished or absent pedal (foot) pulses?YesNoHave you suffered a severe injury to the leg(s) or feet?YesNoDo you have an infection of the leg(s) or feet that may be gangrenous (black skin tissue)?YesNoRecent sweats/feverYesNoUnexplained weight loss/gainYesNoUnexplained fatigue/weaknessYesNoCough/WheezeYesNoDizziness, lightheadedness, passing outYesNoNausea or VomitingYesNoHeadaches/ Visual ProblemsYesNoHearing difficultiesYesNoAbdominal PainYesNoHeartburn, indigestionYesNoChange in Bowel HabitsYesNoDiarrhea and/or ConstipationYesNoBlack stools or blood in stoolYesNoPrinceton Interventional Cardiology, P.A.Office Visit Examination Page 2 of 3Patient Name:__________________________________Date: ______________Your answers on this form will help your health care provider better understand your medical concerns and conditions better. This form will not be put directly into your medical chart. If you are uncomfortable with any question, do not answer it. Thank You.Burning or Pain with urinationYesNoUrinating frequentlyYesNoUrinating during the nightYesNoBlood in urineYesNoMuscle pain , if yes (location ___________________________)YesNoJoint pain, if yes (location ______________________________)YesNoSkin rash, if yes (location ______________________________)YesNoDifficulty sleepingYesNoHow many hours a night sleep do you receive on average____________________ hoursDo you follow a special diet, ie. Fat free, salt free, diabetic, etc._____________________Do you exercise regularly, if so approximately how many hours per day_____________________What Medications are you currently taking, including over-the-counter medications?MedicationDoseHow many times per dayHave you had any surgeries or hospitalizations in the past, please indicate:Do you currently smoke or chew tobacco?YesNoIf yes, how many packs per day_____________If you have a history of smoking; but have quit, how long ago did you quit?_________________________Do you currently drink coffee or tea?YesNoIf yes, number of cups per day_____________Do you currently drink alcohol, beer or wine?YesNoIf yes, how many drinks per week_____________Do you currently, or have a history of, recreationaldrug use?YesNoPrinceton Interventional Cardiology, P.A.Office Visit Examination Page 3 of 3Patient Name:__________________________________Date: ______________Family History:LivingAge (or age at death)IllnessesMotherYesNo_________________________________________FatherYesNo_________________________________________Brother(s)YesNo___________________________________________________________________________________________________________________________Sister(s)YesNo___________________________________________________________________________________________________________________________Has any member of your family (including children, parents, siblings, aunts or uncles) had any of the following illnesses?IllnessFamily MemberAnemia or Blood Disease______________________________________________Cancer______________________________________________Diabetes______________________________________________Heart Disease______________________________________________Peripheral Vascular Disease______________________________________________High Blood Pressure______________________________________________Stroke______________________________________________Have you completed a living will or durable power of attorney for health care?YesNo ................
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