Patient Medical History Form - Mobile Heart Specialists Page 2
ADVERTISEMENT
1
2PRIOR CARDIAC PROCEDURES
Yes
No
When
Where
Angioplasty/Stent(s)
Bypass surgery
Pacemaker
Defibrillator
Ablation
Heart Catheterization
Check if you have had any of the following symptoms in the last six (6) months
CARDIOVASCULAR
MUSCULOSKELETAL
Yes
No
Comments
Yes
No
Comments
Chest pain/pressure
Muscle pain
Pain in legs with walking
Joint pain
Swelling in feet
Joint swelling, deformity
Fast heart rate
Numbness
Shortness of breath at night
GENERAL
Yes
No
Comments
RESPIRATORY
Yes
No
Comments
Changes in sleep patterns
Difficulty breathing
Decrease in activity level
Short of breath with walking
Fatigue
Cough
Wheezing
SKIN
Yes
No
Comments
Bruising
NEUROLOGICAL
Yes
No
Comments
Loss of consciousness/fainting
EYES
Yes
No
Comments
Seizures
Vision changes
Weakness
Memory Loss
HENT
Yes
No
Comments
Unusual headaches
PHYSCHIATRIC
Yes
No
Comments
Nosebleeds
Family/Work Stress
Anxiety
GASTROINTESTINAL
Yes
No
Comments
Depression
Nausea
GENITOURINARY
Difficulty swallowing
Yes
No
Comments
Heartburn
Problems with urination
Constipation
Lack of bladder control
Diarrhea
Erectile Dysfunction
Vomiting
Blood in stools(black tarry stools)
Surgeries:(list)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Version: 6/7/2016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical