Cardiovascular Risk Assessment And Patient History Form

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Cardiac Specialists
Cardiovascular Risk Assessment and Patient History form
Thank you for taking the time to fill out our health questionnaire. This will allow us to better serve your health needs.
This is a confidential record of your medical history and will be kept in this office.
Today’s date: _______________ Name: _______________________________________ Date of Birth: ________________
Primary Care Provider: ____________________________________________________________________________________
Problem Today (Describe any recent testing): __________________________________________________________________
Current Medications and Dosages (If none please write None)
________________________________________________________________________________________________
__________________________________________________ ______________________________________________
__________________________________________________ ______________________________________________
ALLERGIES (Drug, Food, environment) Please circle No or Yes (If Yes please list)_________________________________
_______________________________________________________________________________________________________
Past Medical History: (Please indicate “Y” for Yes or “N” for No, if uncertain write “?”)
____ High Blood Pressure
____ Diabetes
____ High Cholesterol
____ Heart Attack
____ Heart Catheterization
____ Angioplasty
____ Congestive Heart Failure
____ Stroke/TIA
____ Valve problem/Heart murmur
____ Rheumatic fever
____ Loss of Consciousness
____ Asthma
____ Arrhythmia(irregular heart beat)
____ Emphysema
____ Pneumonia
____ Anemia
____ Vascular (blood vessel) Disease
____ Bleeding tendency
____ Ulcer
____ Cancer
____ Liver Disease/Hepatitis
____ Kidney Disease
____ Arthritis
____ Glaucoma
____ Migraine Headaches
____ Thyroid Disease
____ HIV Disease
____ Autoimmune Disease
____ Other __________________________________________________________
Past Surgical History and Hospitalizations: (please list and give approximate dates)
If none please check here _____
1.________________________________________________
2. ________________________________________________
3.________________________________________________
4. ________________________________________________
FAMILY MEDICAL HISTORY:
If no positive family history please check here _____
Has any blood relative had any of the following (Please indicate “Y” for Yes or “N” for No, if uncertain write “?”)
Please document the relationship(father, mother, sibling or other blood relative)
High Blood Pressure __________________________________
Sudden Death _________________________________
Diabetes ___________________________________________
Congestive Heart Failure ________________________
High Cholesterol ____________________________________
Arrhythmia(irregular heart beat) __________________
Heart Attack ________________________________________
Vascular (blood vessel) Disease ___________________
Angioplasty _________________________________________
Cancer _______________________________________
Coronary Bypass Surgery ______________________________
Other _______________________________________
Stroke______________________________________________

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