Southeast Cardiology
NEW PATIENT INTAKE FORMName: ________________________________________________ DOB: _____________________________________________Main Reason for today’s office visit: __________________________________________________________________________Do you have a history of heart problems or heart disease? ? Heart Attack ? Stents in Heart ? Bypass Surgery ?Congestive Heart FailureAre there any family members with heart problems or heart disease? ? No ? Yes? Father ___________________?Brother __________________? Mother ________________?Sister __________________What other medical problems do you have?? Diabetes? Stroke/TIA?High Blood Pressure ? High Cholesterol ? Other: ___________________________Do you smoke? ? No?Quit in ________________?Yes, About _________ per day ?Other: _____________________Do you drink any alcohol? ? No ?Yes, describe: _________________________________________________Do you have any of the following problems or symptoms?? All systems are normalConstitutionalCardiovascularGastrointestinalMusculoskeletal ? Chills?Chest pain or discomfort? Abdominal Pain? Arthritis? Fatigue?Shortness of breath with activity? Nausea? Back Problems? Weight gain ?Palpitation? Diarrhea? Memory Loss? Weight loss?Heart Murmur?Black StoolPsychiatricHead?Leg pain when walking? Vomiting?Anxiety? Dizziness? History of Rheumatic Fever? Vomiting Blood? Depression? Fainting? Difficulty breathing lying down? Rectal BleedingEndocrine? Headaches? Walking with shortness of breathNeurological?DiabetesEyes? Waking with shortness of breath?Weakness? Thyroid problems? Blurred vision? Swelling of legs?NumbnessHematologic?Double visionRespiratory? Paralysis? Anemia? Loss of Vision? Cough? Stroke? Blood clotsSkin?Wheezing? TinglingUrinary? Easy bruising? Coughing up blood? Unsteady gait? Blood in urine? Rashes ? Shortness of breath? Seizures? Kidney StonesReproductive (Females? Sputum?Pregnancy? Birth control ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- southeast florida map printable
- southeast florida homes for sale
- southeast asia population
- southeast asians
- southeast asian countries list
- southeast asian flags
- south and southeast asia map
- southeast asia list
- 11 countries of southeast asia
- southeast asia countries map
- interactive map of southeast asia
- countries in southeast asia list