New Patient Health Questionnaire Form

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TEXAS CARDIOVASCULAR SPECIALISTS
Date: _____/____/______
New Patient Health Questionnaire
Patient: _____________________________
Gender:
M
F
Date of Birth: ____/______/_____________
Age___________
Referring Doctor: ______________________________________________________________________
Please INDICATE all the reasons for your visits.
1.
Chest pain
at rest
with exertion
2.
Shortness of breath
at rest
with exertion
3.
Palpitations/irregular heart rate
4.
Racing heart
5.
Swelling legs
6.
Hypertension
7.
Heart failure
8.
Pre surgical evaluation
9.
Establish new cardiologist
MEDICATIONS:
Please list all prescription and non-prescription medicines including vitamins and aspirin.
NAME
DOSE/STRENGTH
FREQUENCY
Example
Lasix
40mg
2in am/1in pm
1.___________________________
_________________
__________/___________
2.___________________________
_________________
__________/___________
3.___________________________
_________________
__________/___________
4.___________________________
_________________
__________/___________
5.___________________________
_________________
__________/___________
6.___________________________
_________________
__________/___________
7.___________________________
_________________
__________/___________
8.___________________________
_________________
__________/___________
9.___________________________
_________________
__________/___________
10.__________________________
_________________
__________/___________
11.__________________________
_________________
__________/___________
12.__________________________
_________________
__________/___________
H4. DO YOU HAVE ANY ALLERGIES TO MEDICINES?
NO (IF NO NEXT QUESTION)
YES
Please list all medications to which you have an allergy or adverse response and list the reaction (e.g. penicillin-arm
rash)
Medication
Reaction
1.___________________________
___________________________
2.___________________________
___________________________
3.___________________________
___________________________
4.___________________________
___________________________
NO
YES
Are you allergic to iodine, shrimp or shellfish?
NO
YES
Have you received X-ray contrast (myelogram, IVP, CT scan)?
NO
YES
If yes did you have any reaction to the contrast?
H1. PRIOR HEART DISEASE AND TESTING? (PAST MEDICAL HISTORY)
YES
NO (
)
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