Cardiovascular Medicine, P.c. Patient Medical History
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2CARDIOVASCULAR MEDICINE, P.C.
Patient Medical History
PLEASE COMPLETE THIS FORM BEFORE YOUR APPOINTMENT!!
****Bring all current medications to your appointment including vitamins, herbal medications and any over the
counter medications you may be taking. ******
Date of Appointment:_______
Patient Name:____________________________
______
Date of Birth/Age
Allergies: Drugs and reaction:__________________________________________
Food (e.g. Seafood, Shellfish) ____________________________________________
Latex Yes
No
Iodine/x-ray dye Yes No
Risk Factors:
Tobacco use? Yes
Never
Quit
Year Quit_________
If yes – Type: Cigarettes Cigars
Pipe Chewing
How many per day?__ How many years? ___
Street Drugs___Yes___ No______________________________________________
Diabetes? Yes___ No___ Year Diagnosed_______
High Cholesterol? Yes ____ No ___ Year Diagnosed________
Hypertension? Yes __ No__ Year Diagnosed ________
Family History of Coronary disease before 60 yrs of age Yes ______ No _______
Mark if you have ever had or currently have the following and the year.
Blood Clots________________________ Heart Attack_________________________________
Sleep Disorder/Apnea_____________ Stroke/TIA’S_________________________________
Tuberculosis______________________ Chest Pain___________________________________
Lung Disease ______________________ Rheumatic Fever_____________________________
Asthma ____________________________Thyroid disease______________________________
Heart Murmurs_____________________Peripheral Vascular Disease _________________
Kidney Disease_____________________ Blood Transfusions __________________________
Cancer _____________________________Hepatitis ____________________________________
Other____________________________________________________________________________
__________________________________________________________________________________
Operations (Surgeries) or Hospitalization with dates
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Family Cardiac History: (cardiac/vascular history such as:
Social History
Heart attack, bypass surgery, congenital heart problems,
Marital Status______________________
sudden death, arrhythmia, congestive heart failure, stroke,
Employed
Retired
Disabled
stents in legs or heart, pacemaker, Diabetes, etc.)
Occupation _______________________
Father_ living deceased age____________________ Children Sons_____
Daughters _______
History _______________________________________
Mother living deceased age__________________
History _______________________________________
Diet
Regular
Special _____________
Brothers _ages____________________________________
History________________________________________
Alcohol consumption: Yes _____No_____
________________________________________________
Amount________________________
Sisters ages_____________________________________
Exercise: Regular
Occasional
Sedentary
History ________________________________________
Active lifestyle
Unable
_______________________________________________
01/08
_____________________
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