Usf Department of Cardiology

USF DEPARTMENT OF CARDIOLOGY

NEW PATIENT INTAKE FORM

Personal Data

Name: ______Date: ______

Date of Birth: ______Age: ______Occupation: ______

Marital Status: □ Single □ Married □ Divorced □ Widowed

Birth Place: ______Education Level: ______

Reason for Cardiac Referral: ______

Physician referring for Cardiac assessment: ______

Have you seen a Cardiologist (heart doctor) before? □ Yes □ No

If so, please ask them to fax your records our office or bring records with you.

Do you have a pacemaker or other cardiac device? □ Yes □ No

What brand? ______(Medtronic/St Jude/Guidant/Boston Scientific)

Please bring card to appointment.

Have you had any cardiac surgery or procedure (ablation, etc.)? □ Yes □ No

What type of procedure and when? ______

______

Patient’s Social History

Do you work? □ Yes □ No □ Retired If yes, what do you do? ______

Do you currently use or have previously used illicit drugs? □ Yes □ No

If yes, how much, what type and how often? ______

Do you currently use or have previously used (smoke or chew) tobacco? □ Yes □ No

Cigarettes □ Yes □ No____Pack per day for ____ years Date stopped ______

Cigars□ Yes □ No____Pack per day for ____ years Date stopped ______

Pipe□ Yes □ No____Pack per day for ____ years Date stopped ______

Chewing□ Yes □ No____Pack per day for ____ years Date stopped ______

Snuff□ Yes □ No____Pack per day for ____ years Date stopped ______

Do your now or have you ever consumed alcohol? □ Yes □ No

If yes, how much and how often? ______

Do you now or have you ever consumed caffeine? □ Yes □ No

If yes, how much and how often? ______

Current diet/special diet? ______

Exercise □ Yes □ No

Duration and Frequency? ______

How many blocks can you walk at a regular pace without stopping? ______

What makes you stop? ______

How many flights of stairs can you go up without stopping? ______

REVIEW OF SYMPTOMS

Are you currently having or have you had the following problems?

Anemia□ Yes □ No When? ______

Anxiety□ Yes □ No When? ______

Arthritis□ Yes □ No When? ______

Attempted Suicide□ Yes □ No When? ______

Black and Tarry Stools□ Yes □ No When? ______

Blood in Stool□ Yes □ No When? ______

Blood clots in legs/lungs□ Yes □ No When? ______

Blood in Urine□ Yes □ No When? ______

Blood Transfusions□ Yes □ No When? ______

Chronic Bronchitis□ Yes □ No When? ______

Runny or Stuffed Nose□ Yes □ No When? ______

Depression□ Yes □ No When? ______

Change in Bowel Habits □ Yes □ No When? ______Difficulty Hearing □ Yes □ No When? ______Exposure to Asbestos □ Yes □ No When? ______

Corrective lenses?□ Yes □ No When? ______

Eye Pain, Vision Problems/Spots, Blurriness?□ Yes □ No When? ______

Esophageal Reflux□ Yes □ No When? ______Excessive Bleeding □ Yes □ No When? ______

Gallbladder Disease□ Yes □ No When? ______Headache □ Yes □ No When? ______

Dizziness (Syncope or fainting)□ Yes □ No When? ______

Indigestion or Heartburn□ Yes □ No When? ______

Frequent and/or productive cough□ Yes □ No When? ______

Weight change□ Yes □ No When? ______

Nervousness□ Yes □ No When? ______

Chest pain, discomfort or pressure□ Yes □ No When? ______

Back pain that radiates around to chest □ Yes □ No When? ______

Palpitations□ Yes □ No When? ______

Fatigue / Feeling tired□ Yes □ No When? ______

Difficulty in breathing/Shortness of breath□ Yes □ No When? ______

Leg pain w/excertion (leg claudication)□ Yes □ No When? ______

Awakening at night with shortness of breath □ Yes □ No When? ______

Excessive sweating□ Yes □ No When? ______

Abdominal pain □ Yes □ No When? ______

Fever(s)□ Yes □ No When? ______

Chills□ Yes □ No When? ______

Vomiting□ Yes □ No When? ______

Neck pain□ Yes □ No When? ______

Jaw pain□ Yes □ No When? ______

Excessive urination□ Yes □ No When? ______

Sleep w/ extra pillows or sleeping upright□ Yes □ No When? ______

Numbness or tingling in extremities□ Yes □ No When? ______

Fast heart rate□ Yes □ No When? ______

Slow heart rate□ Yes □ No When? ______

Irregular heart rate□ Yes □ No When? ______

Wheezing□ Yes □ No When? ______

Swelling in legs, hands and/or feet□ Yes □ No When? ______

Rapid breathing□ Yes □ No When? ______

Coldness in hands and/or feet□ Yes □ No When? ______

REVIEW OF SYMPTOMS (CONTINUED)

Hemorrhoids □ Yes □ No When? ______

High Triglycerides□ Yes □ No When? ______

HIV □ Yes □ No When? ______

Hoarseness or Voice Change □ Yes □ No When? ______

Indigestion/ Heartburn□ Yes □ No When? ______

Joint stiffness, Pain or Swelling □ Yes □ No When? ______

Kidney Stones□ Yes □ No When? ______

Loss of Appetite □ Yes □ No When? ______

Nausea or Vomiting□ Yes □ No When? ______

Nervousness□ Yes □ No When? ______

Night Sweats□ Yes □ No When? ______

Need to Get Out of Bed to Urinate? □ Yes □ No How often? ______

Pain in Legs While Walking□ Yes □ No When? ______

Painful Urination □ Yes □ No When? ______

Pneumonia □ Yes □ No When? ______

Previous Mental Illness □ Yes □ No When? ______Renal Failure/Iodine Allergies □ Yes □ No When? ______Rheumatic Fever □ Yes □ No When? ______

Ringing in Ears □ Yes □ No When? ______

Seizures□ Yes □ No When? ______

Severe Nose Bleeds □ Yes □ No When? ______

Shortness of Breath W/Exertion□ Yes □ No When? ______

Shortness of Breath Laying Flat in bed □ Yes □ No When? ______

Sinus Problems□ Yes □ No When? ______

Spells of Unconsciousness □ Yes □ No When? ______

Stomach Ulcers □ Yes □ No When? ______

Stroke□ Yes □ No When? ______

Swelling of the Legs/Ankles□ Yes □ No When? ______

Syncope (fainting spells)□ Yes □ No When? ______

Thirst or Frequent Urination □ Yes □ No When? ______

Thyroid Disease □ Yes □ No When? ______

Tuberculosis□ Yes □ No When? ______

Urinary Tract Infections□ Yes □ No When? ______

Weight Change□ Yes □ No When? ______

Wheezing□ Yes □ No When? ______

Yellow Jaundice or Liver Disease □ Yes □ No When? ______

Migraine headaches□ Yes □ No When? ______

Family History

Has anyone in your family (mother, father or sibling) had a heart attack? □ Yes □ No

If yes, how old were they when it occurred? ______

Has anyone in your family (mother, father or sibling) had “sudden cardiac death” or died at a young age inexplicably? □ Yes □ No

Mother:

If living, current age ______If deceased, age at death: ______

History of heart disease: □ Yes □ NoCause of death: ______

If yes, what age diagnosed? ______

□Diabetes

□High Cholesterol

□Hypertension

□Coronary Artery Disease

□Cardiomyopathy

□Arrhythmias

□Heart Failure

Overall health of mother: ______

Father:

If living, current age ______If deceased, age at death: ______

History of heart disease: □ Yes □ NoCause of death: ______

If yes, what age diagnosed? ______

□Diabetes

□High Cholesterol

□Hypertension

□Coronary Artery Disease

□Cardiomyopathy

□Arrhythmias

□Heart Failure

Overall health of father: ______

Siblings:

Age: ______Sex: ______Health: ______

PAST MEDICAL HISTORY – Cardiac

Do you currently have or have ever had any of the following diseases?

Rheumatic Fever□ Yes □ NoWhen diagnosed? ______

How treated? ______

Heart Murmur□ Yes □ NoWhen diagnosed? ______

How treated? ______

Heart Attack (MI)□ Yes □ NoWhen diagnosed? ______

How treated? ______

High Cholesterol□ Yes □ NoWhen diagnosed? ______

How treated? ______

High Blood Pressure □ Yes □ NoWhen diagnosed? ______

How treated? ______

Diabetes□ Yes □ NoWhen diagnosed? ______

How treated? ______

Irregular Heart Beat□ Yes □ NoWhen diagnosed? ______

How treated? ______

Palpitations□ Yes □ NoWhen diagnosed? ______

How treated? ______

Congenital Heart Disease□ Yes □ NoWhen diagnosed? ______

How treated? ______

Valvular Heart Disease□ Yes □ NoWhen diagnosed? ______

How treated? ______

Enlarged Heart□ Yes □ NoWhen diagnosed? ______

How treated? ______

Cardiomyopathy□ Yes □ NoWhen diagnosed? ______

How treated? ______

Congestive Heart Failure□ Yes □ NoWhen diagnosed? ______

How treated? ______

Coronary Artery Disease□ Yes □ NoWhen diagnosed? ______

How treated? ______

Peripheral Vascular Disease□ Yes □ NoWhen diagnosed? ______

PAST MEDICAL HISTORY - OTHER

How treated? ______

COPD□ Yes □ NoWhen diagnosed? ______

How treated? ______

Asthma□ Yes □ NoWhen diagnosed? ______

How treated? ______

Emphysema□ Yes □ NoWhen diagnosed? ______

How treated? ______

Kidney Disease□ Yes □ NoWhen diagnosed? ______

How treated? ______

Liver Disease□ Yes □ NoWhen diagnosed? ______

How treated? ______

Cancer □ Yes □ NoWhen diagnosed? ______

What type? ______How treated? ______

Bleeding Disorders□ Yes □ NoWhen diagnosed? ______

How treated? ______

Stroke (CVA or ICH)□ Yes □ NoWhen diagnosed? ______

How treated? ______

Thyroid disorders (hyper, hypo)□ Yes □ NoWhen diagnosed? ______

How treated? ______