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Patient History Form

How did you hear about us?

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Current Providers:

Primary Care:

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Cardiologist:

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What are you here for today?

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Please answer all questions that apply to you by circling or filling in the answer

Heart

Chest Pain

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Palpitations

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Passing out

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Shortness of Breath

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Dizziness Last Stress Test

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Last Echo

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Legs

Have you ever worn prescribed compression stockings? No Yes- from

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Leg symptoms: check ail that apply

Tingling

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Swelling in Feet/Legs

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Wounds

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Burning

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Pain

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Spider veins

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Numbness

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Cramps

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Varicose veins

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Heaviness

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Skin discoloration

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Hair Loss

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How long have your leg symptoms been present?

days

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weeks

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months

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years

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Do you have problems with both legs?

Yes

No

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If both legs, does one leg bother you more than the other?

Right

Left

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What symptoms are worse with activity?

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What symptoms are worse with rest?

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Do you have trouble sleeping at night due to your legs?

Yes

No

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Medical History: Circle ail that apply

Stents

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Bypass

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Pacemaker

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High Blood Pressure

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GERD/acid reflux

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Stroke

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Blood Clots

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Diabetes

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Congestive Heart Failure

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High Cholesterol

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COPD

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Asthma

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Sleep Apnea

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Thyroid problems

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Kidney Disease

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Other:

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Preventative Care: Please give dates for most recent if applicable

Colonoscopy:

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PSA(men only)

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HgbA‘1c:

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Urine Albumin:

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Diabetic Eye Exam:

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Diabetic Foot Exam:

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Women: Last Mammogram

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Last Pap Smear

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Total number:

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Pregnancies:

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Miscarriages

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Live births

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Last Menstrual cycle

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Are you pregnant now?

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Hysterectomy?

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If yes, was it total/complete or partial?

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Surgeries, serious injuries, illnesses, or hospitalizations: Please give date

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List all allergies and reactions:

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Family History:

Father

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Mother

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Brother

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Sister

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Living?

Yes

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Yes

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Yes

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Yes

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No

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No

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No

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No

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Social History:

Do you smoke?

Yes

Never

Former

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If former, when did you quit?

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How long have you smoked?

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How many packs per day?

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Do you use any other tobacco products (including vapes)?

Yes

Never

Former

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Do you drink alcoholic beverages?

Yes

No

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History of alcoholism?

Yes

No

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What do you drink?

Beer

Wine

Liquor

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How many drinks per week?

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How many caffeinated drinks per day?

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Sodas

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Coffee

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Tea

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Energy Drinks

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Do you use recreational drugs?

Yes

No

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If yes, what kind?

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