PATIENT INFORMATION
REFERRING PHYSICIAN
REASON
PREVIOUS SURGERIES TO HEART OR BLOOD VESSELS
DATE TYPE OF SURGERY
PREVIOUS HOSPITALIZATIONS FOR HEART, VESSELS, LUNGS OR KIDNEYS
DATE REASON OF HOSPITALIZATION

(Please Complete Information Below)

(Please Complete Information Below)

MEDICAL HISTORY (Check/ Fill in all that apply)
  • Seasonal Allergies
  • Food Allergies
  • Repaired Abdominal Aneurysm (Stomach)
  • Thoracic Aneurysm (Chest)
  • Carotid Aneurysm (Neck)
  • Renal Aneurysm (Kidney)
  • Popliteal Aneurysm (Knee)
  • Other Aneurysm
  • Arthritis
  • Asthma
  • Benign Prostatic Hypertrophy
  • Bleeding Disorder
  • Cancer
  • Radiation
  • Chemotherapy
  • Carotid Stenosis (narrowing)
  • Cataracts
  • Head Circulation Problems
  • Stroke or TIA
  • Neck Circulation Problems
  • Arms Circulation Problems
  • Hand Circulation Problems
  • Legs Circulation Problems
  • Peripheral Angioplasty (non-heart)
  • Peripheral Stent (non-heart)
  • Coronary Artery Bypass
  • Coronary Artery Angioplasty/ Stent
  • Coronary Artery Disease
  • Heart Attack
  • Heart Faliure
  • Heart Valve Disease
  • Deviated Septum
  • Diabetes Mellitus
  • Age of Diabetes Diagnosis
  • Diabetes Diet Controlled
  • Insulin Dependent
  • Oral Diabetes Medication
  • Emphysema
  • Oxygen Dependent
  • DVT (Vein Blood Clot)
  • DVT Location
  • Clot in Lungs
  • Gallstones
  • Gastroesophageal Reflux (GERD)
  • Glaucoma
  • Gout
  • Gynecological Problems
  • Hearing Problems/ Aids
  • Hepatitis
  • High Colesterol
  • High Blood Pressure
  • HIV/AIDS
  • Hyperthyroidism
  • Hypothyroidism
  • Irritable Bowel Syndrome
  • Osteoporosis
  • Kidney Problems
  • Peritoneal Dialysis
  • Hemodialysis
  • Hyperthyroidism
  • BUN (if known)
  • Creatinine (if known)
  • Lupus
  • Depression
  • Anxiety
  • Pacemaker/ Defibrillator
  • Other Mental Disorder
  • Peptic Ulcer Disease
  • Bleeding Ulcer
  • Raynaud's Disease
  • Seizures/ Epilepsy
  • Sleep Apnea
  • CPAP/ BIPAP
  • Varicose Veins
  • Other
  • Other
  • Other
SOCIAL HISTORY
FAMILY HISTORY (please check any condition below that any blood relative has experieneced and note relationship (e.g. Father, Sister, etc.)
  • Alcoholism
  • Allergies
  • Amputation
  • Aneurysm
  • Asthma
  • Blood Clots in Legs
  • Blood Clots in Lungs
  • Blood Clotting Problems
  • Blood Thinning Medication
  • Cancer
  • Cholesterol Problem
  • Chron's Disease
  • Circulation Problems (Leg/Arm)
  • Cirrhosis
  • Colitis
  • Diabetes
  • Easy Bleeding/Bruising
  • Emphysema
  • Heart Attack
  • Heart Disease
  • High Blood Pressure
  • Irritable Bowel Disease
  • Lupus
  • Rheumatoid Arthritis
  • Seizures or Epilepsy
  • Stroke
  • Thyroid Trouble (Goiter)
  • Tuberculosis
  • Varicose Veins
  • Other:
MEDICATIONS/ AllERGIES (Are you allergic or have you had a "bad reaction" to?)
Medication Name Dosage (Amount) Frequency (How Often)
REVIEW OF SYSTEMS (check/fill in all that apply)

Cardiovascular

  • Chest Pain
  • Anemia
  • Ankle Swelling
  • With Excercise
  • Blood Clots
  • Fainting
  • At Rest
  • High Blood Pressure
  • Irregular Heart Beat

Endocrine

  • Intolerant Heat or Cold
  • Hair Loss
  • Sweating(Night Sweats)

Eyes, Ears, Nose and Throat

  • Blindness in one eye
  • Blurry Vision
  • Change in Vision
  • Deafness
  • Hoarseness
  • Lack of Vision in Visual field
  • Loose and/or Painful Teeth
  • Nosebleeds
  • Post Nasal Drip
  • Ringing in Ears
  • Shade Going Over Eye
  • Sores in Mouth

Gastrointestinal

Abdominal Pain
  • Abdominal Bloating
  • Change in Appetite
  • Constipation
  • Diarrhea
  • Difficulty Swallowing
  • Foul-smelling, Dark Stool
  • Heartburn
  • Joundice
  • Nausea
  • Painful Swallowing
  • Vomiting
  • Vomiting Blood
  • Weight Gain
  • Weight Loss
  • If Over Age 50:
  • Date of last Endoscope:
  • Sigmoidoscopy:
  • Colonoscopy:

Gynecological (Females Only)

Hematological

Blood Clotting
If yes, Specify
Artery
Vein
  • Easy Bruising
  • Prolonged Bleeding

Musculoskeletal/Skin

  • Back Pain
  • Cramping with Excercise
  • Finger Sores
  • General Weakness
  • Gout
  • Heaviness/Achiness in Legs
  • Joint Pain/Stiffness
  • Leg Fatigue w/Prolonged Standing
  • Neck Pain
  • Numbness and/or Tingling
  • Skin Color Changes
  • Sores on Legs and/or Feet
  • Leg Pain at Rest
  • Upper Extremity Discomfort with Activities
  • Lower Extremity Discomfort with Activities
How Far can You Walk?

Neurological

Difficulty Moving a Side or Limb
Numbness of a Side or Limb
  • Dizziness
  • Head Trauma
  • Headache
  • Loss of Consciousness
  • Memory Loss
  • Paralysis
  • Seizures
  • Shakiness
  • Slurred Speech
  • Tremors
  • Weakness

Respiratory

  • Cough
  • Coughing up Blood
  • Wheezing
Shortness of Breath
If yes, Specify
At Rest
With Exertion
Snoring

Psychological

  • Change in Sleeping Patterns
  • Depression
  • Difficulty Concentrating
  • Feeling of Hopelessness
  • Feeling of Helplessness
  • Guilty Feelings
  • Hearing Voices
  • Loss of Sexual Desire
  • Nervousness
  • Social Withdrawl
  • Tension
Mental Abuse
Physical Abuse
Thoughts of Suicide*

Urological

  • Blood in Urine
  • Flank Pain
  • Frequent Urination
  • Kidney Stones
  • Incontinence
  • Pain with Urination