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PATIENT INFORMATION
- Please underline the correct alternative and/or enter the required information to the empty
lines -
First and last name: _____________________________________________________________
Date of birth:_______________________ Gender: male / female
Weight: _____________________________ Height: ___________________________________
Do you smoke? Yes / No. If you smoke, how long have you been smoking?_________________
If you have quit smoking, when did you quit? ________________________________________
Do you have diabetes? Yes / No. Are you taking insulin treatment? Yes / No.
Do you have arterial hypertension? Yes / No.
Have you been diagnosed with a pulmonary disease (e.g. asthma, chronic obstructive pulmonary
disease)? Yes / No.
If yes, what was the result of the spirometry? FEV1 _____________ VC__________________
Do you have any neurological condition? Yes / No.
If yes, please describe:___________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Condition of teeth? Treated / not treated
Do you have intermittent claudication symptoms (pain in the calves when walking)? Yes / No.
If you have intermittent claudication symptoms, how far can you walk before the symptoms
begin? _______________ metres.
Have you been diagnosed with carotid artery stenosis? Yes / No.
Have you undergone carotid ultrasonography? Yes / No.
If yes, what was the result?
_____________________________________________________________________________
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Have you undergone contrast-enhanced imaging of the coronary arteries (coronary
angiography)? Yes / No. If yes, when?_______________________________________________
What was the result? ____________________________________________________________
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Have you undergone heart surgery? Yes / No. If yes, when and what kind?
_____________________________________________________________________________
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Have you undergone any other surgery? Yes / No. If yes, when and what kind?
_____________________________________________________________________________
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Do you have any liver disease? Yes / No. If yes, which?
_____________________________________________________________________________
Do you suffer from an illness that may cause bleeding? Yes / No.
If yes, what kind (e.g. gastric ulcer, blood disease, cancer, sequel to cerebral haemorrhage)?
_____________________________________________________________________________
Do you have any allergies? Yes / No. If yes, to which drug or substance?
_____________________________________________________________________________
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How did the allergy manifest itself?________________________________________________
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Are you HIV positive? Yes / No.
Have you been diagnosed with hepatitis? Yes / No.
Have you been diagnosed with diphtheria? Yes / No.
Laboratory values:
Plasma creatinine: _______________ If you have a nephropathy, which is it?
_____________________________________________________________________________
Total cholesterol level: ___________ Haemoglobin: __________________________________
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Cardiac symptoms:
Do you experience chest pain? Yes / No.
If yes, what is the chest pain like (aching, tingly, burning, pressing, tearing)?
In which situations do you feel chest pain? __________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
At which level of strain does the chest pain occur? When walking uphill / walking on even
ground / dressing / at rest.
How long does the chest pain usually last? A few minutes / half an hour / a couple of hours / the
whole day.
Does a fast-acting nitro help with the chest pain? Yes / No. How quickly does the nitro
help?_________________________________________________________________________
How many fast-acting nitros do you use in a week? _____________ in a day?_______________
Has the chest pain increased lately (within one or two months)? Yes / No.
Have you recently (within three months) suffered a myocardial infarction? Yes / No
Do you experience shortness of breath? Yes / No.
If you do, in which situations does this occur?________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Do you have arrhythmia symptoms (e.g., palpitations, rapid or slow heart rate)? Yes / No
If yes,
Does the arrhythmia start suddenly? Yes / No
Does the arrhythmia stop suddenly? Yes / No
Does the pulse (heart beat) feel regular during the arrhythmia? Yes / No
What is the average heart rate during the arrhythmia? ________ beats per minute / I do not
know
How long does the arrhythmia last?
A few minutes / a couple of hours / whole day / several days / the arrhythmia is constant.
How often do you experience arrhythmia?
Once or twice a year / once a month / weekly / daily
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Please describe the symptoms you have during the arrhythmia:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Have you been diagnosed with any of the following arrhythmias? Atrial fibrillation / Atrial
flutter / Supraventricular tachycardia (SVT) / Ventricular tachycardia / Ventricular or atrial
extrasystole
Is ECG document of the arrhythmia available? Yes / No
Do you have a pacemaker? Yes / No. Installed in the year ______________________________
Have you been diagnosed with a valvular heart defect? Yes / No. If yes, please describe:
_____________________________________________________________________________
_____________________________________________________________________________
Have you undergone echocardiography? Yes / No. Do you know what the results were?
_____________________________________________________________________________
_____________________________________________________________________________
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Have you undergone a stress test? Yes / No. Do you know what the results were?
_____________________________________________________________________________
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Have you been in hospital treatment during the past year? Yes / No. Where?
_____________________________________________________________________________
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Do you have any regular medication? Yes / No.
Please specify the name and dose of each medication.
_____________________________________________________________________________
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_____________________________________________________________________________
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If necessary, please enter an additional description of your health problems in your own words:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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_____________________________________________________________________________
What wishes related to your condition do you have?___________________________________
_____________________________________________________________________________
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What other health-related information would you like to inform us of?
_____________________________________________________________________________
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