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Date:________________________________ Patient Name:________________________ Referred by:_________________________ Mailing Address:_____________________ Telephone:___________________________ Your Email Address:__________________ Date of Birth:_______________________ Gender: Male Female Primary Care Physician Name, Address and Phone:__________________ Emergency Contact Name:______________ Relationship:________________________ Phone:_______________________________ Your Height:_________________________ Your Weight:_________________________ What seems to be the problem? What is the reason for consultation? Do you have high blood pressure or are you taking a blood pressure medication?
No I Don't Know
I have never smoked I used to smoke, but have quit
No I Don't Know
Yes, I was diagnosed prior to age 21 No
No
No
No
I have a moderate level of stress I have a high level of stress
Moderately Active (about 30 minutes of activity 3 days per week) Not Active
Moderate Drinker (1-2 drinks per day) Heavy Drinker (3 or more drinks per day) I don't drink
No
No
No
No
No These are basic questions. There are many more. When should you call Emergency Medical Services? Do you have any of these symptoms, signs, or problems? New chest pain or discomfort that is severe, unexpected, and occurs with shortness of breath, sweating, nausea, or weakness. Palpitations with a resting adult heart rate of more than 100 per minute. Palpitations with a resting adult heart rate of more than 100 per minute five minutes after brisk walk or exercise. Shortness of breath not relieved by rest. Fainting spell with loss of consciousness. New irregular heartbeat. Chest pain or discomfort during activity that is relieved with rest. Difficulty breathing during regular activities or at rest. Decreased urination. Restlessness, confusion. Constant dizziness or lightheadedness. Nausea and vomiting. Q) What seems to be the problem? Q) Has this been a problem before? Q) How long have you had this problem? Q) Are you seeing a doctor? Q) Who is your next of kin? Q) Are you taking any medication? Q) Have you ever had this type of pain before? Q) Describe what's wrong. Palpitations Lightheadedness or Dizziness Syncope (loss of consciousness) Chest Pain or Chest Discomfort Q) Where is it? Does it radiate? Q) What is it like? Q) How bad is it? (For pain, ask for a rating on a scale of 1 to 10.) Q) When did (does) it start? How long did (does) it last? How often did (does) it come? Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. Q) Does anything make it better or worst? Q) Have you noticed anything else that accompanies it? Q) What brought it on? Q) What relieved it? Q) Did it move to the shoulder, arms, jaw, back or other parts of the body? Q) Were there associated symptoms like shortness of breath, sweating, dizziness, weakness, nausea, vomiting, etc.? Q) When did it first start? Q) How often does it occur? Q) If it was initially brought on by exertion, is the pattern changing? Q) Is it brought on by lesser amounts of exertion? Q) Is it becoming more frequent with time? Q) Are the symptoms lasting longer? Q) Do they appear at rest or has it awakened the patient from a sound sleep? Answers to these questions are analyzed by the physician and help him or her determine the cause of the pain and the seriousness of the problem. A case history is very important. Without a correct case history, case management can go wrong. Why are you seeing the Doctor today? Are you age appropriate Immunized? Are you currently pregnant? Have you ever had general anesthesia? Have you ever had problems with anesthesia? Do you have any children? Do you live alone? Are you on a special diet? PLEASE ANSWER ALL QUESTIONS What is your reason for today’s visit? 1. When did the problem/discomfort start? 2. Where is the problem/discomfort located? 3. What makes it worse? 4. If there are any other symptoms associated with this problem please describe GENERAL REVIEW OF SYSTEMS Are you currently having any of the following symptoms? (Please circle yes or no) Constitutional: Genitourinary: Neurological: Y N Recent weight change Y N Frequent urination Y N Syncope/Passing out Y N Fever Y N Burning or painful urination Y N Near Syncope Y N Chills Y N Blood in urine Y N Headaches Y N Fatigue Y N Incontinence or dribbling Y N Lightheaded Y N Kidney stones Y N Dizziness Eyes: Y N Sexual difficulty Y N Convulsions or seizures YN Blurred/impaired vision Y N Erection Problems Y N Numbness or tingling Y N Tremors ENT: Musculoskeletal: Y N Paralysis YN Hearing loss Y N Joint pain Y N Stroke YN Ringing in ears Y N Joint stiffness or swelling Y N Head injury YN Nose bleeds Y N Weakness of muscles/joints Y N Slurred speech YN Bleeding gums Y N Muscle pain or cramps YN Sore throat or voice change Y N Back pain Endocrine: YN Swollen glands in neck Y N Cold extremities Y N Thyroid disease Y N Leg pain with walking Y N Diabetes Cardiovascular: Y N Leg swelling Y N Excessive thirst Y N Chest pains/discomfort Y N Limb weakness Y N Excessive urination Y N Sudden heart beat changes Y N Heat or cold intolerance Y N Palpitations/racing heart beat Skin: Y N Dry skin Y N Swelling of feet, ankles or hands YN Rash YN Itching skin Hematologic/Lymphatic: Respiratory: YN Change in skin color Y N Slow to heal after cuts Y N Frequent coughing YN Varicose veins Y N Bleeding tendencies Y N Sputum productive cough YN Easily bruise Y N Anemia Y N Spitting up blood YN Non-healing sores Y N Shortness of breath Adverse Reactions to: Y N Asthma or wheezing Psychiatric: Y N Penicillin or antibiotics Y N Memory loss or confusion Y N Morphine. Demerol, narcotics Gastrointestinal: Y N Nervousness Y N Novocain, other anesthetics Y N Loss of appetite Y N Depression Y N Aspirin or other pain remedies Y N Change in bowel movements Y N Sleep problems Y N Tetanus antitoxin, other serum Y N Nausea Y N Suicidal thoughts Y N Iodine, methiolate, antiseptics Y N Vomiting Y N Frequent diarrhea List all allergies that you have: Y N Painful bowel movements/constipation Y N Blood in stool Y N Stomach pain Y N Heartburn Y N Reflux Please list all PRESCRIPTION medications that you take List all OVER THE COUNTER medications that you take Name Dose Frequency Name Dose Frequency Past Medical History: (Check all that apply) _____ Heart Disease _____ Previous Heart Attach _____ Asthma _____ Cancer _____ Heart Valve Problems _____ High Blood Pressure _____ COPD _____ Bleeding Disorder _____ Pacemaker _____ High Cholesterol _____ Thyroid Disease _____ HIV Disease/exposure _____ Heart Failure _____ Blood Clot in Legs _____ Liver Disease _____ Hepatitis (A, B or C) _____ Heart Block _____ Blood Clot in Lungs _____ Kidney Disease _____ Hereditary Heart Defect _____ Lung Problems _____ Stroke _____ Heart Murmur _____ Emphysema _____ Diabetes Please provide information about previous surgeries and hospitalizations (include date or year) Surgeries / Procedures Hospitalizations Date Admitted for Date Coronary Bypass Cardiac Cath Date Date Angioplasty / Stent Date Date Pacemaker Date Date Defibrillator Date Date Other Date Date Date Date Please provide information about previous testing (include date and location) Stress Test Date _____ Location Holter Monitor Date _____ Location Nuclear Test Date _____ Location Event Monitor Date _____ Location Echo Date _____ Location Heart Scan Date _____ Location 24 hr BP Monitor Date _____ Location PAD Net Date _____ Location Does anyone in your family have or had Heart Disease, Heart Attack, Stroke, High Cholesterol, High Blood Pressure, Diabetes, Diabetes, Sudden Death or Cancer? Father Age _____ Disease(s) Cause of death, if deceased Mother Age _____ Disease(s) Cause of death, if deceased Siblings Age _____ Disease(s) Cause of death, if deceased _______ Age _____ Disease(s) Cause of death, if deceased _______ Age _____ Disease(s) Cause of death, if deceased _______ Age _____ Disease(s) Cause of death, if deceased Social History: Cigarette Smoking: Never Current: _____ pack(s) per day, _____ year’s total Previous: _____ year quit Use of Alcohol: Never Rare/Social Moderate Daily: amount per day _____ Previous: _____ year quit Use of Caffeine: Never Rare/Social Moderate Daily: amount per day _____ Previous: _____ year quit Exercise Level: Never Rare Moderate Daily _____ times per week. Type of exercise: Special Diet: Low Fat Low Is anyone coming with you to your first visit to our center? If so, please give name and relationship_______________________________________________________________________ Is your mother still living? Yes No If no, please give approximate age and cause of death___________________________________________________________________________ Is your father still living? Yes No If no, please give approximate age and cause of death___________________________________________________________________________ Are you brothers/sisters still living? Yes No If no, please give approximate age and cause of death___________________________________________________________________________ Your Health No Before the age of 20, did you have any major illnesses beyond the usual childhood illnesses? Yes If yes, please describe: _______________________________________________________________ Please list surgeries and approximate date, or circle NONE: _______________________________________________________________________________ _______________________________________________________________________________ Please list allergies to medications or to foods, or circle NONE: _______________________________________________________________________________ Please list your current medications: Med Name Each Time(s) About how long have you been Dose (mg) usually taken taking this medication? each day Are there any other medications that you took regularly but stopped within the past 3 months? (Please do not forget to include aspirin.) __________________________________________________________ Please include doses, times, and types if you take insulin. If you have diabetes, how often do you check your blood sugar? Where does your blood sugar usually run in the morning before breakfast? What is the highest your blood sugar has been during the past week? What is the lowest your blood sugar has been during the past week? Have you had times in the past 3 months when have had symptoms that you think were due to low blood sugar? Do you take medicines that do not need prescriptions? Aspirin or other pain medications? If so what, how many times/week? ___________________ Laxatives? ____________________________ Vitamins? Herbal medicines? Do you smoke now? Yes No If yes: Cigarettes _____ packs/week Cigars _____ /week If no, have you smoked in the past? Yes No For how many years? What are the most you have smoked regularly? ____________ packs/day. How many times a week do you drink alcohol? If none, when is the last time that you remember having an alcoholic drink? How many caffeine beverages do you usually drink in a day? _________________________________ Describe any regular exercise (e.g. walking ½ mile, stationary bicycle, etc.) ____________________ ____________________________________How often each week? ___________________________. Have you had any difficulties with the following: Eating? Hygiene? Dressing? Walking? Toileting? Getting into or out of bed? Please check any of the following that you have had; give approximate year of first diagnosis: Heart Attack (list all known) __________ Gout __________ Coronary artery disease __________ Skin conditions requiring medications __________ Enlarged or weak heart __________ TB (tuberculosis) __________ “Heart Failure” __________ Pneumonia __________ Cardiomyopathy __________ Blood disorders __________ Rheumatic fever (usually in childhood) ______ AIDS or HIV positive __________ Heart murmur __________ Cancer: if yes, what type? __________ Heart valve disease __________ Liver disease, hepatitis, or yellow jaundice ______ Heart rhythm problem __________ Thyroid condition (too high or too low) _________ Kidney problems High blood pressure __________ Kidney stones Urinary tract infections Pulmonary Embolism (blood clot in lung arteries) Blood in urine _____________ Difficulty urinating Phlebitis; venous thrombosis; blood clots in leg veins Raynaud’s Phenomenon Diabetes __________ Elevated Cholesterol _________ No if yes, have you taken medications Seizures: Yes Asthma: if yes, how may times a week do you use for seizure? Yes No if yes, What medications have you inhalers? _________/wk taken? ____________ Muscle disease: _________________________________________ (dystrophy or peripheral myopathy) _________________________________________ Connective tissue diseases: _________________________________________. Lupus Scleroderma Rheumatoid arthritis Other: _____________________ Please check any symptoms if you have had them in the past two years: 4 Chest pain or discomfort ………………………………………………………………….. How frequently?_____________________________________ When did this start?___________________________________ On a scale of 1-10, 10 being the greatest, how would you describe this pain?_________ Palpitations (fluttering of the heart, sensation of several extra or irregular heart beats) If so, when was the first time? ____________ when was the most recent time? _____________ What was the longest an episode has lasted? ______________________ Shortness of breath when walking, climbing stairs, or carrying bundles ..………………… Shortness of breath when you lay down or wake up in the night ………………………… Abnormal breathing or snoring at night ………………………………………………….. Swelling in your feet or ankles ………………………..……………………………………………….. Difficulty with coordination……………………………………………………………….. Pain or cramping in your legs/calves with walking or exercise ………………………….. Temporary loss of strength or feeling in arm, leg, or face ………………………………... Temporary difficulty with speech or understanding ……………………………………… Dizziness that doesn’t go away within a few minutes of standing up ……………………. Fainting episode, where you lost consciousness …………………………………………. Have you lost or gained more than 10 pounds in the last three months without trying to or wanting to lose weight? Problems with vision Discomfort or difficulty with urination Problems with hearing Commonly feeling hotter or colder than others Pain in teeth or gums Recurring fevers or chills Persistent cough Recurring joint swelling or pain Frequent throat pain or difficulty Frequent pain, tingling or numbness in your swallowing feet Coughing up blood Difficulty with balance Persistent nausea or vomiting Skin rashes Frequent abdominal pain Sores that don’t heal Recurrent diarrhea or constipation Easy bruising White fingers or toes during exposure to cold Are there other symptoms that you feel of which we should be aware? Have you been diagnosed with depression? Yes No If yes, have you taken medicine for depression? Yes No If yes, what medications? Have you ever been hospitalized for depression or other psychiatric condition? Yes No Have you taken medication for anxiety during the past year? Yes No If so, how often? Approximately how many hours do you sleep per night? Have you taken medication to help you sleep in the past year? Yes No If so, how often? How often do you take naps during the day? Have you ever felt unsafe or been afraid of anyone? Is anyone trying to control you or your children? Has anyone ever hurt or threatened to hurt you or someone else that you care about? PAST HISTORY: After obtaining information about the chief complaint, the physician will inquire about the past history. This will include questions about diseases such as diabetes, high blood pressure, elevated cholesterol levels, prior surgery, asthma, stroke, cancer, allergies, etc. This information may also strengthen a suspected diagnosis. For example, the presence of diabetes, high blood pressure and high cholesterol is known to increase the risk of heart disease. FAMILY HISTORY: Certain cardiac illnesses such as coronary artery disease and high blood pressure may occur in more than one member of a family. Therefore, the physician will inquire about the health of the patient's parents, brothers, sisters and children. Similarly, risk factors for coronary artery disease, such as diabetes, high cholesterol, etc., may be prevalent in the same family. SOCIAL HISTORY: Information about smoking and drinking is sought because of tobacco's undeniable link to coronary artery disease. Similarly alcohol can weaken the heart muscle in susceptible individuals, and caffeine can provoke irregular heartbeats. The physician will also inquire about the patient's work and family if he or she feels that stress is contributing to, or aggravating the patient's illness. REVIEW OF SYSTEMS: This is a "laundry list" of symptoms related to various organs of the body. A series of questions are designed to seek out information that the patient may have neglected to provide the physician. A history of asthma during childhood, for example, may be discovered this way and keep the physician from prescribing certain heart medicines that may provoke an asthmatic attack. The history dictates whether or not the patient needs further work-up or testing, and the urgency with which they should be carried out. Should the patient be hospitalized because there is a threat of an impending heart attack? Is the likelihood of disease low enough that testing can be obtained at a more leisurely pace? Subsequent testing helps to identify the patient's problem, or exclude different parts of the differential diagnosis. Physical Exam After obtaining a history, the physician proceeds to perform a physical examination. Depending upon the patient's condition and suspected medical problem, a physician may include one or more of the following four phases of the physical examination: Inspection Palpation or "hands-on" examination Percussion or "tapping" examination Auscultation or use of stethoscope |