CLINICAL INFORMATION
Please Complete and Bring to Your Office Visit
Name:________________________________________________ Appointment Date:______________________
Date of Birth:_______________________ Age:____________ Sex:  Male  Female
Reason for Today’s Office Visit:____________________________________________________
______________________________________________________________________________
Please list all current medications:
Medication
Strength/Dose
Medication
Strength/Dose
Are you allergic to any medications? If so, list:______________________________________________________
Are you allergic to iodine or seafood? Yes  No
Have you ever had a reaction to iodine or IV contrast? Yes  No
IN EACH SECTION BELOW PLEASE CHECK ALL THAT APPLY TO YOU
History of Present Illness
Have you recently experienced:
Chest Pain/Pressure, Tightness, Heaviness
Dizziness, Passing Out, Fainting
Shortness of Breath
Yes
No
Have you recently experienced:
Irregular Heart Beat
Swelling - where___________
Pain in Legs with Exercise
Yes
Review of Systems
Do you get short of breath when you walk or
exercise?
Do you sleep on more than 1 pillow to help
you breathe at night?
Recent weight loss
Recent weight gain
Fever / chills
Decreased exercise tolerance
Wear glasses / contacts
Partial vision loss
Cataracts currently
Glaucoma
Hearing loss
Nose bleeds
Difficulty speaking
Emphysema (COPD)
Thyroid Problems
Diabetes
Heart Racing
Have you recently had chest pains
Hip or leg cramps when you walk less than 2
blocks?
Do you wake up from sleep having trouble
breathing?
Current blood or mucus in stools?
Stomach ulcers
Arthritis
Blood clots in legs
Varicose veins
Stroke
Stroke with paralysis
Anxiety / nervousness
Depression
Use of illegal drugs
Attempted suicide
High Cholesterol
Allergy to Foods
Bleeding disorders
Seasonal allergies
Allergy to medications
No
Heart skipping beats
Feet / Ankle swelling
Urinary or bowel problems
Blackout or fainting spells
Past Medical History
Abdominal Aneurysm
Asthma
Anemia
Anxiety
Arthritis
Cancer (Type?)________________
Congenital Heart Disease
Congestive Heart Failure/Fluid in Lungs
Depression
Diabetes
Diverticulitis
Emphysema/COPD/Lung Problems
GERD /Acid Indigestion
Gout
Hiatal Hernia
Kidney Disease
Leg or Hip Cramps
Liver Disease
Neck : large artery blockage
Parkinson’s Disease
Seizures
Stomach Ulcer or Bleeding Ulcer
Stroke with or without Paralysis
Thyroid Problems
Past Cardiac History
Chest Pain (Angina)
Congestive Heart Failure
Heart Murmur / Valve Disease
Heart Attack: How Many?
Blockage of Heart Arteries (Coronary Artery
Disease)
High Cholesterol
Hypertension
Atrial Fibrillation
Date(s) of Heart Attack(s):
Other Heart Rhythm Problems
Infection History
Hepatitis
HIV +
Other:
Rheumatic Fever
TB (Tuberculosis)
Trauma History
Cardiac Contusion
Head Injury
Surgical History
Heart Valve Replacement  Mitral  Aortic
Carotid Artery Surgery (neck)
Pacemaker / ICD Implant
Open Heart Bypass Surgery When?________
How many bypasses?__________
Breast Surgery
Cataract Removal
C-section
Gallbladder Removal
Other: (please list)
Gastric Bypass/Lapband/Stomach Stapling
Hemorrhoid Surgery
Hernia Surgery
Hip/Knee Replacement (please circle)
Hysterectomy
Kidney Surgery
Lung Surgery
Thyroid Surgery
Prostate Surgery (TURP)
Vascular Procedures
Femoral/Popliteal Bypass Surgery:  Right  Left  Bilateral
Angioplasty or Stent in Legs:  Right  Left  Bilateral
Cardiac Procedures
Heart Catheterization
How Many?
EP Study (Electrophysiology)
PTCA (Balloon Angioplasty) How Many?
Stent (wire coil) placed in heart artery
How Many?
Kidney / Renal Stenting
Event Monitor
Cardioversion
Heart Cath Dates :
Ablation
PTCA Dates:
Stent Dates:
Which Artery?
Echocardiogram
Holter Monitor
Stress Test
Cardiac Risk Factors
History of Tobacco Use
Family History of Heart Disease
High Cholesterol
High Blood Pressure
Diabetes
Previous Heart Disease
History of Obesity
No Regular Exercise
Reached Menopause
Take Hormones
Social History/Other Cardiac Risk Factors
Drink Alcohol Regularly(drinks per wk _____)
Drink Alcohol Occasionally/Socially
No Alcohol
Smoke Currently ( packs per day ______ )
Used to Smoke but Quit
History of or Current Drug Use? What type?
Eat a Special Diet? (circle below)
Low Salt/ Low Cholesterol/ Low Fat/ Diabetic
No Diet Modifications
Exercise Regularly days per wk _______
No Regular Exercise
Caffeine Use: Coffee, Soda Tea: How Much?
Family History
Heart Problems:
 Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles
High Blood Pressure:  Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles
Stroke:
 Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles
Cancer:
 Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles
Glaucoma:
 Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles
Diabetes:
 Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles
Seizures:
 Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles
Problems Bleeding:
 Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles
Kidney Problems:
 Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles
Thyroid Disease:
 Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles
Mental Illness:
 Father  Mother  Grandparents  Child  Brother  Sister  Aunts/Uncles