HCMG Cardiology Associates of Boca Raton
9980 Central Park Blvd. N., Ste. 304, Boca Raton, FL 33428
Patient History
NAME: ______DATE: ______
HCMG Cardiology Associates of Boca Raton
9980 Central Park Blvd. N., Ste. 304, Boca Raton, FL 33428
Patient History
GENERAL HEALTH
q Fatigue
q Fever/shaking chills
q Loss of appetite
q Loss of weight
q Joint stiffness
SKIN
q Psoriasis
q Hair Loss
q Rash
q Easy Bruising
q Shingles
CARDIOVASCULAR
q High Blood Pressure
q Angina
q Heart Attack
q Stroke
q Heart Murmur
q Palpitations
q Rheumatic Fever
q Shortness of Breath
PULMONARY
q Asthma
q Pneumonia/Bronchitis
q Emphysema
q Tuberculosis
HCMG Cardiology Associates of Boca Raton
9980 Central Park Blvd. N., Ste. 304, Boca Raton, FL 33428
Patient History
METABOLIC DISEASES
q Diabetes
q Thyroid
q Elevated Cholesterol
q Elevated Triglycerides
GASTROINTESTINAL
q Ulcers
q Hiatus Hernia
q Diverticulosis
q Colitis
q Hepatitis
q Jaundice
q Gall Bladder
URINARY TRACT
q Kidney Infections
q Bladder Infections
q Kidney Stones
q Blood in Urine
NEUROLOGIC-PSYCHIATRIC
q Seizures
q Neuropathy
q Muscle Pain
q Muscle Weakness
HCMG Cardiology Associates of Boca Raton
9980 Central Park Blvd. N., Ste. 304, Boca Raton, FL 33428
Patient History
HEAD & NECK
q Headaches
q Glaucoma
q Cataracts
q Dry Eyes/Mouth
BLOOD DISORDERS
q Anemia
q Low White Count
q Low Platelet Count
q Bleeding Problems
EXTREMITIES
q Phlebitis
q Varicose Veins
q Leg Cramps/night
q Leg Cramps/walking
SMOKING HISTORY
q Past______Yr Quit
______# of packs
______# of years
q Present
______# of packs
______# of years
ALCOHOL
q Present
q Past
HCMG Cardiology Associates of Boca Raton
9980 Central Park Blvd. N., Ste. 304, Boca Raton, FL 33428
Patient History
SURGERIES/OPERATIONS
YEAR______TYPE______
YEAR______TYPE______
YEAR______TYPE______
OTHER HOSPITALIZATIONS
YEAR______TYPE______
YEAR______TYPE______
YEAR______TYPE______
FAMILY HISTORY
Specify Disease:
Father: ______
Mother: ______
Siblings: ______
Other: ______
______
Physician Signature______
PROCEDURES
Catheterization______Date______
Echocardiogram______Date______
Stress Test______Date______
MEDICATIONS
______
______
______
______
______
ALLERGIES
______
______