New Patient Visit Questionnaire

Name
DOB
Home No
Cell No
Work No
Email
Address
City
State
Zip
Primary Care Physician
Office Address
Work No
Email
Referring Physician (if different)
Office Address
Work No
Email
Pharmacy
Address
Phone No
Email
Medication prescription preference (select one)
Emergency Contact: 
Name
Number
Relation
Why are you here to see a cardiologist today?  Please be as specific as possible (e.g. symptoms or tests.)
Do you currently smoke?
Did you ever smoke?
Did you ever use chewing tobacco or snuff?
Do you currently drink?
Are you
Do you currently work?
Occupation
Have you ever had non-cardiac surgery before?
If yes, please indicate dates and types of surgery:
PAST MEDICAL HISTORY:

Do you personally have a history of:Details (e.g. dates, hospitals, treating physicians)

Known coronary artery disease?
"Silent" heart attack (found incidentally)?
Heart attack(s) requiring hospitalization
Coronary artery stenting
Coronary artery ballooning only
Coronary artery bypass surgery
Heart rhythm disorders?
Pacemaker?
Defibrillator (ICD)?
Atrial fibrillation?
Atrial flutter?
PVCs or VT?
Cardioversion?
Ablation procedure?
First Name Alive? (Y/N) Age Heart Disease? High Cholesterol? Diabetes? Stroke? Cancer? Emphysema or COPD?
Father
Mother
Brother(s)
Sister(s)
Sons(s)
Daughter(s)
Other(s)
For any family member you have indicated “yes” for heart disease above, please list the specific details below (e.g. heart attack, stents, bypass surgery, valve disease, atrial fibrillation, etc.) as well as the age of onset of the disease.  If any family member dies suddenly, please indicate the age at death and if the cause was heart-related (e.g. heart attack, sudden death, stroke, etc.)
Family memberAge at onset/deathType of heart disease/Cause of death
Do you have a living will?
Do you have a health care proxy?
If yes, please list contact information below:
Name
Relation
Address
Home No
Cell No
Work No
Email
Do you have any ALLERGIES to medication?
If yes, please list medications and reactions:
Medication (name) Amount Frequency taken  (daily, every 6 hours, etc.) Approximate start date of medication
Do you take any non-prescription medications?
If yes, please list below:
REVIEW OF SYSTEMS: Please indicate IF YOU ARE CURRENTLY EXPERIENCING any of the following signs and/or symptoms:
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Dr. Mellow is the most compassionate doctor I’ve ever seen

Regina Miles

Dr. Mellow is the most compassionate doctor I’ve ever seen

Regina Miles

Dr. Mellow is the most compassionate doctor I’ve ever seen

Regina Miles

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