John F. Hagaman, MD, FACC
J. Brandt McCabe, MD, FACC
Andrew J. Shanahan, MD, FACC
Banu Mahalingam, MD, FACC
CARDIOLOGY ASSOCIATES OF PRINCETON, PA
PATIENT NAME
An accurate history is important for us to give you the best treatment recommendations possible.
Please complete both sides of this form.
Why are you here?
Referring Physician:
Primary Physician:
Prior Surgery (Type/Year/Surgeon)
Operations (circle):
Last Colonoscopy:
Last Sigmoidoscopy:
Medical Problems (Circle or add diseases)
Diabetes
Hypertension
Prostate
Asthma
Heart Disease
MVP
Hepatitis
High Cholestrol
COPD
Atrial Fib
Gastrointestinal
Stroke
Ulcers
Heart Attack
Thyroid
Polyps
Valve/Joint Replacement
Kidney
Glaucoma
Cancer (type)
Other:
Prior Chemotherapy?
Prior Radiation?
Do you have a heart murmur?
Do you take antibiotics for dental work?
Gallbladder
Appendix
Hysterectomy
Breast
Vascular
Hernia
C-section
Hemorrhoids
Orthopedic
Tonsils
D and C
Cancer surgery
Heart Colon
Pacemaker/Defibrillation unit
Medications you are currently taking:
Do you take:
Aspirin
Coumadin
Ticlid
Herbal Supplementa?
Allergies to medicines (Reaction type?)
Family Medical History
Latex allergy?
Habits
Smoking?
Alcohol?
Caffeine?
Exercise?
Packs/Day
Years?
(Never, Daily, Weekly, Rarely)
Cups/day?
Type
Motrin
Plavix
OB/GYN History:
Number of Pregnancies?
Number of Children?
Last Menstrual Period?
Do you have a Living Will?
Your Pharmacy:
Pharmacy Phone Number:
TO BE COMPLETED BY PATIENT – Review of Systems
NAME
CONSTITUTIONAL SYMPTOMS
Good general health lately…………………..... No
Recent weight change……………………….... No
Fever………………………………………….... No
Fatigue…………………………………………. No
Headaches……………………………………… No
EYES
Eye disease or injury………………………….. No
Wear glasses/contact lenses…………………… No
Blurred or double vision………………………. No
Glaucoma……………………………………… No
EARS/NOSE/MOUTH/THROAT
Hearing loss or ringing……………………….. No
Earaches or drainage………………………….. No
Chronic sinus problems or rhinitis…………… No
Nose bleeds……………………………………. No
Mouth sores…………………………………… No
Bleeding gums………………………………… No
Bad breath or bad taste……………………….. No
Sore throat or voice change…………………… No
Swollen glands in neck………………………… No
CARDIOVASCULAR
Heart trouble…………………………………… No
Chest pain or angina pectoris…………………. No
Palpitation……………………………………… No
Shortness of breath with walking/lying flat….. No
Swelling of feet, ankles or hands……………… No
RESPIRATORY
Chronic or frequent coughs……………………. No
Spitting up blood………………………………. No
Shortness of breath…………………………….. No
Asthma or wheezing…………………………… No
GASTROINTESTINAL
Loss of appetite………………………………… No
Change in bowel movements…………………. No
Nausea or vomiting……………………………. No
Frequent diarrhea………………………………. No
Painful bowel movements or constipation……. No
Rectal bleeding or blood in stool………………. No
Abdominal pain………………………………… No
GENITOURINARY
Frequent urination……………………………... No
Burning or painful urination…………………... No
Blood in urine………………………………….. No
Change in force of stream when urinating……. No
Incontinence or dribbling………………………. No
Kidney stones………………………………….No
Sexual difficulty……………………………….. No
Male – testicle pain……………………………. No
Female – periods: pain/irregular (circle) ……… No
Female – vaginal discharge……………………. No
MUSCULOSKELETAL
Joint pain……………………………………….. No
Joint stiffness or swelling……………………… No
Weakness of muscles or joints………………… No
Muscle pain or cramps…………………………. No
Back pain……………………………………….. No
Cold extremities………………………………... No
Difficulty in walking…………………………… No
INTEGUMENTARY (skin, breast)
Rash or itching…………………………………. No
Change in skin color……………………………. No
Change in hair or nails…………………………. No
Varicose veins………………………………….. No
Breast pain……………………………………… No
Breast lump…………………………………….. No
Breast discharge……………………………….. No
NEUROLOGICAL
Frequent or recurring headaches………………. No
Light headed or dizzy………………………….. No
Convulsions or seizures………………………… No
Numbness or tingling sensation……………….. No
Tremors……………………………………….... No
Paralysis…………………………………………No
Stroke……………………………………………No
Head Injury…………………………………….. No
PSYCHIATRIC
Memory loss or confusion…………………….. No
Nervousness……………………………………. No
Depression……………………………………… No
Insomnia……………………………………….. No
ENDOCRINE
Glandular or hormone problem……………….. No
Thyroid disease………………………………….No
Diabetes (insulin/non-insulin - circle one)….. No
Excessive thirst or urination…………………… No
Heat or cold intolerance……………………….. No
Skin becoming dryer…………………………… No
HEMATOLOGICAL/LYMPHATIC
Slow to heal cuts/bruising…………………….. No
Anemia…………………………………………. No
Phlebitis………………………………………… No
Past Transfusion……………………………….. No
Enlarged glands………………………………… No
ALLERGIC/IMMUNOLOGIC
History of skin reaction or other adverse reaction to:
Penicillin or other antibiotics………………….. No
Morphine, Demerol, or other narcotics………… No
Novocaine, Lidocaine or other anesthetics…….. No
Aspirin or other pain remedies…………………. No
Iodine. Methiolate or other antiseptic…………. No
Known food or other allergies:
PHYSICIAN
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DATE:
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