Healthy Hearts – Healthy Hearts Patient History

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Healthy Hearts Patient History

Please choose your office*
- ENCINO
- MISSION HILLS
- VALENCIA
- WESTWOOD
FULL NAME
DATE
MM slash DD slash YYYY
AGE
DOB
MM slash DD slash YYYY
HEIGHT
WEIGHT
Marital Status
- Single
- Married
- Widow
- Divorced
- Separated
OCCUPATION
HOW DID YOU HEAR ABOUT US
REFERRING PHYSICIAN 1
REFERRING PHYSICIAN 2
REASON FOR CONSULTATION 1
REASON FOR CONSULTATION 2
REASON FOR CONSULTATION 3
PREVIOUS DIAGNOSIS OF HEART DISEASE
- YES
- NO
IF YES PLEASE ELABORATE 1
IF YES PLEASE ELABORATE 2
IF YES PLEASE ELABORATE 3
IF YES PLEASE ELABORATE 4
CHEST PAIN
- YES
- NO
SHORTNESS OF BREATH
- YES
- NO
PALPITATIONS
- YES
- NO
SWELLING OF ANKLES
- YES
- NO
DIZZINESS – SYMPTOM
- YES
- NO
FAINTING
- YES
- NO
HEART MURMUR
- YES
- NO
HIGH BLOOD PRESSURE
- YES
- NO
HIGH CHOLESTEROL
- YES
- NO
DIABETES
- YES
- NO
HEART ATTACK
- YES
- NO
STROKE
- YES
- NO
LAST ELECTROCARDIOGRAM DATE
MM slash DD slash YYYY
LAST ELECTROCARDIOGRAM
- NORMAL
- ABNORMAL
LAST CHEST X-RAY DATE
MM slash DD slash YYYY
LAST CHEST X-RAY
- NORMAL
- ABNORMAL
LAST TREADMILL TEST DATE
MM slash DD slash YYYY
LAST TREADMILL
- NORMAL
- ABNORMAL
PRIOR CARDIAC PROCEDURES 1
PRIOR CARDIAC PROCEDURES 2
PRIOR CARDIAC PROCEDURES 3
PRIOR CARDIAC PROCEDURES 4
PRIOR CARDIAC PROCEDURES COMPLICATIONS 1
PRIOR CARDIAC PROCEDURES ANY COMPLICATIONS 2
DESCRIBE ANY OTHER MEDICAL CONDITIONS OR DIAGNOSES 1
DESCRIBE ANY OTHER MEDICAL CONDITIONS OR DIAGNOSES 2
DESCRIBE ANY OTHER MEDICAL CONDITIONS OR DIAGNOSES 3
PRIOR NON-CARDIAC PROCEDURES 1
PRIOR NON-CARDIAC PROCEDURES 2
PRIOR NON-CARDIAC PROCEDURES 3
PRIOR NON-CARDIAC PROCEDURES 4
PRIOR NON-CARDIAC PROCEDURES ANY COMPLICATIONS 1
PRIOR NON-CARDIAC PROCEDURES ANY COMPLICATIONS 2
SMOKING HABITS
- NEVER A SMOKER
- PREVIOUS SMOKER
- CURRENT SMOKER
Current smoker Quantity
ALCOHOL HABITS
- YES
- NO
DESCRIBE ALCOHOL
EXCERCISE HABITS
- YES
- NO
DESCRIBE EXCERCISE
COFFEE HABITS
- YES
- NO
DESCRIBE COFFEE
SPECIAL DIET HABITS
- YES
- NO
DESCRIBE SPECIAL DIET
FATHER – IF LIVING AGE
FATHER – HEALTH
FATHER – IF DECEASED AGE
FATHER – CAUSE OF DEATH
MOTHER – IF LIVING AGE
MOTHER – HEALTH
MOTHER – IF DECEASED AGE
MOTHER – CAUSE OF DEATH
BROTHERS – IF LIVING AGE
BROTHERS – HEALTH
BROTHERS – IF DECEASED AGE
BROTHERS – CAUSE OF DEATH
SISTER – IF LIVING AGE
SISTER – HEALTH
SISTER – IF DECEASED AGE
SISTER – CAUSE OF DEATH
WEIGHT GAIN
- YES
- NO
lbs. GAIN
WEIGHT LOSS
- YES
- NO
lbs. LOSS
RESPIRATORY COUGH
- YES
- NO
RESPIRATORY SLEEP APNEA
- YES
- NO
ABDOMINAL PAIN
- YES
- NO
CONSTIPATION
- YES
- NO
PAINFUL URINATION
- YES
- NO
INCREASED FREQUENCY
- YES
- NO
JOINT PAIN
- YES
- NO
HEADACHE
- YES
- NO
DIZZINESS
- YES
- NO
Do your legs ever feel tired, causing you stop and rest?
- YES
- NO
When you walk do you ever have to stop because you have pain or cramping in your calves or thighs?
- YES
- NO
Do you ever experience cramping, tightness, "Charlie Horses" or pain in the legs and feet when lying down that improves when you stand up?
- YES
- NO
Has anyone ever told you that you have poor circulation in your legs, intermittent claudication or periheral arterial disease?
- YES
- NO
DRUG 1
DOSAGE & FREQUENCY 1
DATE FIRST PRESCRIBED 1
PHYSICIAN 1
DRUG 2
DOSAGE & FREQUENCY 2
DATE FIRST PRESCRIBED 2
PHYSICIAN 2
DRUG 3
DOSAGE & FREQUENCY 3
DATE FIRST PRESCRIBED 3
PHYSICIAN 3
DRUG 4
DOSAGE & FREQUENCY 4
DATE FIRST PRESCRIBED 4
PHYSICIAN 4
DRUG 5
DOSAGE & FREQUENCY 5
DATE FIRST PRESCRIBED 5
PHYSICIAN 5
DRUG 6
DOSAGE & FREQUENCY 6
DATE FIRST PRESCRIBED 6
PHYSICIAN 6
DRUG 7
DOSAGE & FREQUENCY 7
DATE FIRST PRESCRIBED 7
PHYSICIAN 7
DRUG 8
DOSAGE FREQUENCY 8
DATE FIRST PRESCRIBED 8
PHYSICIAN 8
DRUG ALLERGIES
- YES
- NO
DRUG ALLERGIES COMMENTS
IODINE OR CONTRAST AGENTS
- YES
- NO
IODINE OR CONTRAST COMMENTS
OTHER ALLERGIES
- YES
- NO
OTHER ALLERGIES COMMENTS
NUMBER OF CHILDREN
Please enter a number less than or equal to 20.
NUMBER OF PREGNANCIES
Please enter a number less than or equal to 20.
MENOPAUSE
- YES
- NO

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