New Patient Intake Form
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2Boulder Medical Center, P.C.
Department of Cardiology
New Patient Intake Form
Patient Name
DOB
Age
Date
Primary Care Physician
Referring Physician
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
Y
N
Blurred/impaired vision
Y
N
Erection Problems
Y
N
Numbness or tingling
Y
N
Tremors
ENT:
Musculoskeletal:
Y
N
Paralysis
Y
N
Hearing loss
Y
N
Joint pain
Y
N
Stroke
Y
N
Ringing in ears
Y
N
Joint stiffness or swelling
Y
N
Head injury
Y
N
Nose bleeds
Y
N
Weakness of muscles/joints
Y
N
Slurred speech
Y
N
Bleeding gums
Y
N
Muscle pain or cramps
Y
N
Sore throat or voice change
Y
N
Back pain
Endocrine:
Y
N
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
Y
N
Rash
Y
N
Itching skin
Hematologic/Lymphatic:
Respiratory:
Y
N
Change in skin color
Y
N
Slow to heal after cuts
Y
N
Frequent coughing
Y
N
Varicose veins
Y
N
Bleeding tendencies
Y
N
Sputum productive cough
Y
N
Easily bruise
Y
N
Anemia
Y
N
Spitting up blood
Y
N
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 See Reverse Side
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