Cardiovascular Medicine, P.c. Patient Medical History Page 2
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2Please list previous cardiac procedures with dates:
(Stress test, EKG, Echocardiogram, Heart Cath, etc.)
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PLEASE CHECK ONLY WHAT IS A CURRENT OR LONG STANDING PROBLEM
Central Nervous System
Comments
Skin & Breast
Comments
seizures
breast lump
light headedness
change in color of mole
vertigo (spinning)
sores that won’t heal
decreased alertness
numbness and tingling
migraine headaches
itchy skin
unilateral weakness
rash
frequent headaches
Kidney/Bladder
unsteady walk
urinary frequency/burning
tremors/convulsions
blood in urine
difficulty with speech
prostate problems (males)
Eye, Ear, Nose & Throat
vision problems
hearing loss
Musculoskeletal
ringing in ears
joint pain/swelling
sinus problems
swelling of feet/ankles
frequent colds
joint stiffness
unilateral loss of vision
muscle weakness
difficulty swallowing
pain in legs when walking
Stomach/Intestine
heartburn
Respiratory (lungs)
indigestion
cough
diarrhea
shortness of breath lying down
diarrhea after meals
coughing up blood
blood in stools
wheezing
abdominal discomfort
shortness of breath at night
Blood/Lymph Glands
shortness of breath
abnormal bruising
abnormal bleeding
Psychiatric
swollen glands
anxiety
depression
Endocrine
mood swings
hotter/colder than others
flushing
Miscellaneous
fever, chills
Allergies/Immunology
unusual wt gain/loss _______ lbs
seasonal allergies
unusually tired
frequent infections
loss of appetite
PATIENT SIGNATURE _________________________________________________
DATE ______________________
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