Patient Medical History Form

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Cardiothoracic and Foregut Surgery
39141 Civic Center Drive, Suite 335
Fremont, CA 94538
(510) 248-1400
Patient Medical History Form
Instructions:
To provide you with the utmost quality of care, we request that you complete this form in its
entirety.
Medical and Social History
Chief Complaint
What is the main reason for your visit today?
(describe in detail)
Do you suffer from any of the following?
If ü YES, please specify…
1. Heart and / or Blood Pressure Problems
q High Blood Pressure
q Angina Pectoris
q Heart Attacks:
How many:
When?
q Heart Failure
q Previous Coronary Stenting / Ballooning
When
q Previous Coronary Bypass Surgery:
When?
q Heart Valve Problems
q Previous Heart Valve Operations
When?
q Other Heart Problems?
Specify
2. Vascular Problems
If ü YES, please specify…
q Previous Stroke or TIA
q Previous Carotid Surgery (neck)
When?
q Pain in your legs
q Non-healing wounds in your legs
q Previous Vascular Surgery
When?
q Aortic Aneurysm
q Previous Aneurysm Surgery:
When?

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