Past Medical History
Patient Name: _____________________________ Date: ________ Date of Birth: ____________________
Yes
No
Past Medical History
AAA/Aneurysm
Anemia
Anxiety
Arthritis
Asthma
Cancers Type?
Lung Disease (COPD)
CVA/Strokes or Seizures
Dizziness
Diabetes Type?
History or current blood clots
Shortness of breath
Swelling in extremities
Excessive fatigue
Gallbladder issues/disease
Acid reflux
Hernia(s) List:
Thyroid problems
Auto Immune disorders
Kidney disease
Panic attacks
Prostate issue(s) List:
Sleep Apnea
Have you ever passed out?
Infectious History
Hepatitis (A, B, C)
HIV/AIDS
MRSA/VRE
Shingles
Rheumatic Fever
Scarlet Fever
Syphilis
Tuberculosis
Typhoid Fever
Yes
No
Cardiovascular History
Chest pains/pressure
Chest tightness
Chest discomfort
Coronary Artery Disease
Cardiomyopathy
Congestive Heart Failure
Hyperlipidemia (High Cholesterol)
Hypertension (High Blood Pressure)
Hypotension (Low Blood Pressure)
Heart valve issues (e.g. Stenosis)
Heart Murmur
Palpitations (Racing, Fluttering, or
Skipped Beats)
Heart Attack / Myocardial Infarction
Cardiovascular Testing/Date
Echocardiogram (Heart Ultrasound)
Treadmill Stress Test
Nuclear Stress Test
Event or Holter Monitor
Pacemaker/AICD Implant
EKG
Invasive Procedures
Heart Catheterizations
Stent Placement
Peripheral Vascular Procedures
Other
Major Bodily Trauma
Concussions
Major Surgeries
Please list anything not mentioned
on the reverse side of this page.
Page 2
Patient Name: ____________________________________________ Date of Birth: __________
Risk Factor Screening
Have you ever smoked/used tobacco?
If so, how often?
Do you still smoke?
Do you exercise? If so, how often?
Yes
No
Are you on a special diet?
Do you drink coffee?
Do you drink tea?
Do you drink soda?
Do you consume other caffeinated
products? If so, what are they?
Are you post-menopausal?
Have you ever used drugs or Marijuana? If so,
what type?
Family History
Details
Do you drink alcohol? If so, how often?
Have they ever had heart problems/disease, stroke, diabetes, cancers,
high cholesterol or high blood pressure? If so, please specify.
Father
Is your father deceased?
Mother
Is your mother deceased?
Brothers (collectively)
How many?
Deceased?
Sisters (collectively)
How many?
Deceased?
Allergies
List of Medications
Reaction?
Dose
How many times per day?
Are you allergic to any medications? If so, please list them below.
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