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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? Yes No I Don't Know What are your smoking habits? I currently smoke I have never smoked I used to smoke, but have quit Do you have high cholesterol or are taking a cholesterol lowering medication? Yes No I Don't Know Do you have diabetes? Yes, I was diagnosed as an adult (over 21 years old) Yes, I was diagnosed prior to age 21 No Have you ever had a heart attack or stroke? Yes No Have you ever had any heart procedures, such as stents, balloon angioplasty or bypass surgery? Yes No Has anyone in your immediate family (father, mother, sibling) had a heart attack? Yes No How would you describe your stress level? I have minimal or low stress I have a moderate level of stress I have a high level of stress How would you describe your level of physical activity? Very Active Moderately Active (about 30 minutes of activity 3 days per week) Not Active I would best describe my alcohol usage as the following Light Drinker (less than 1 drink per week) Moderate Drinker (1-2 drinks per day) Heavy Drinker (3 or more drinks per day) I don't drink Do you follow a low fat, low carb or vegetarian diet? Yes No Do you eat red meat, packaged foods, fast food, or fried food 3 or more times per week? Yes No Do you eat fish 3 or more times per week or take a daily fish oil supplement? Yes No Do you currently have any periodontal diseases such as gingivitis? Yes No Do you take aspirin daily? Yes 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.