New Patient Health Questionnaire Form Page 2
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4TEXAS CARDIOVASCULAR SPECIALISTS
NO
YES: YEAR: ________
Heart murmur/valve prolapse…………………….
Location:__________________
NO
YES: YEAR: ________
Rheumatic/Scarlet fever…………………………….
Location:__________________
NO
YES: YEAR: ________
Angina/Chest pain………………………………………
Location:__________________
NO
YES: YEAR: ________
Heart attack……………………………………………….
Location:__________________
NO
YES: YEAR: _______
Heart Cath/Angioplasty/Stent……………………
Location:__________________
NO
YES: YEAR: ________
Bypass surgery …………………………………………
Location:__________________
NO
YES: YEAR: ________
Pacemaker…………………………………………….……
Location:__________________
NO
YES: YEAR: ________
Defibrillator……………………………………………….
Location:__________________
NO
YES: YEAR: ________
Heart failure………………………………………………
Location:__________________
NO
YES: YEAR: ________
Stress test (treadmill)……..…………………………
Location:__________________
NO
YES: YEAR: ________
Echo/Ultrasound ………………………………………..
Location:__________________
.
NO
YES: YEAR: ________
Calcium Scoring…………………………………………
Location:__________________
NO
YES: YEAR: ________
Nuclear Thallium PET scan…………………………
Location:__________________
NO
YES: YEAR: ________
Carotid ultrasound……………………………………
Location:__________________
NO
YES: YEAR: ________
CT Angiogram……………………………………………..
Location:__________________
NO
YES: YEAR: ________
Holter (24hr monitor)……………………………
Location:__________________
H2. RISK FACTORS FOR HEART DISEASE:
NO
YES: YEAR: ________
High cholesterol………………………………………
TC____LDL____HDL____TG____
NO
YES: YEAR: ________
High blood pressure.…………………………………
NO
YES: YEAR: ________
Y
N
Diabetes……………….…………………………………….
Hormones
NO
YES:
Current Smoker……………………………………..……
NO
YES: YEAR QUIT: _______
Previous Smoker…….…………………………………..
NO
YES: YEAR: ________
Fen-Phen weight loss medicine.………………….
H3. BLOOD VESSEL DISEASES
NO
YES: YEAR: ________
Carotid disease or endarterectomy.……………
NO
YES: YEAR: ________
Stroke or TIA (mini-stroke)………………………….
NO
YES: YEAR: ________
Aortic aneurysm ………………………………………
Surgical Repair Year_____________
NO
YES: YEAR: ________
Numbness or tingling of legs……………………….
NO
YES: YEAR: ________
Leg cramps while walking…………………………...
NO
YES: YEAR: ________
Venous thrombosis (leg clots)……….…………...
NO
YES: YEAR: ________
Pulmonary embolism (lung clots)…………….….
H5. PAST SURGICAL HISTORY (OPERATIONS)
NO
YES
Do not relist the cardiac operations already listed.
Example: appendectomy
YEAR: 95
Location: Medical City
1.___________________________
YEAR________
Location: ______________________
2
.___________________________
YEAR________
Location: ______________________
3.___________________________
YEAR________
Location: ______________________
4.___________________________
YEAR________
Location: ______________________
5.___________________________
YEAR________
Location: ______________________
6.___________________________
YEAR________
Location: ______________________
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