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Download Patient History Assessment - Cardiovascular Clinic of Hattiesburg
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Cardiology Patient History Assessment Name: _________________________________________________ Date of Birth: ___________________________ Date: _________________ Referring Physician: ____________________________________________ Please answer the following questions prior to your visit with the doctor. This will assist greatly in your evaluation and care. 1) Please describe the main symptoms that led to your referral to the cardiologist: 2) How long have these symptoms been occurring: 3) Do you have any of the following Symptoms: Yes Chest Pain? Shortness of Breath with Exertion? Do you awaken at night short of breath? - If yes, how many pillows do you sleep on? ___ Do you have dizzy spells? Do you have sudden lightheadness with: Sudden standing? Prolonged standing? Bending Over? Have you ever fainted? Do you feel your heart pounding or racing? - If yes, How often? ____________________ - If yes, How long does it last? ____________ No Feet/ Ankle Swelling? Leg Pain/Cramps when walking? Varicose Veins? Clots in Legs (DVT)? Non-healing wounds in legs/ feet ? Cough? Wheezing? Coughing up blood? Asthma? Impotence/ Erectile Dysfunction? Yes No Please circle all medial conditions you have presently or have had in the past: Heart Attack High Cholesterol High Blood Pressure Are you allergic to: Diabetes Sleep Apnea Bypass Surgery Aspirin Yes No Valve Replacement Acid Reflux Stroke CT/ X-Ray Dye Yes No Arrhythmia Thyroid Disease Hital Hernia Penicillin Yes No Please list any additional Drug Allergies you have: Please list below any member of your immediate family who has ever had a heart attack, diabetes, angioplasty or bypass surgery, cardiac arrhythmia or sudden death. Please list the ages of any immediate family member who have died and the cause of death. Mother: Brother(s): Father: Sister(s): Page 1 of 2 Please list all previous surgeries you have undergone: HABITS Do you smoke? Do you chew tobacco? - If No, Have you ever done so in the past? Do you drink alcoholic beverages? - If yes, how much per day of each week? ________ Wine ________ Beer ________ Spirits Do you drink caffeinated beverages? Yes No How much/ How long? _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Marital Status: (Circle One) Single Married Divorced Widowed Do you have children? Yes No If Yes, how many? ______________________________________ Are you currently employed? Yes No What is your occupation? _________________________________________________________________________ Please check YES or NO to the following listed symptoms or problems or fill in the blank when necessary: CONSTITUTIONAL YES Fever Excessive Fatigue Snoring Recent Weight Gain Sleepiness During the Day EYES Glaucoma Eye Disease Change in Vision EAR, NOSE, MOUTH and THROAT Decrease in Hearing Ringing of the ears Nose Bleed Tooth ache/ cavities Dental prosthesis GASTROINTESTINAL Abdominal Pain Blood in Stool/ Black Stools Nausea/ Vomiting Stomach or Intestinal Ulcers Reflux disease or heartburn Diarrhea Constipation Vomiting Blood LIVER AND PANCREAS Liver Disease Pancreas Disease Hepatitis Cirrhosis NO GENITO-URINARY YES NO Prostate Disease (Male) Blood in your Urine Difficulty Urinating Excessive Urination GYNECOLOGICAL (FEMALES) Hysterectomy Excessive Vaginal Bleeding Post-Menopausal Are you Pregnant? Last Menstrual Period: __________________ ENDOCRINE Muscle Pain Gout Arthritis or joint pain NEUROLOGICAL Stroke Seizures Weakness on One Side Depressed Numbness/ Tingling on one side SKIN Skin Ulcers Change in Skin Color Easy Bruising Rash HEMATOLOGICAL Anemia Low Platelets Cancer Page 2 of 2
