Frank Rubalcava MD Ted Trusevich MD Yasser Farra DO Ronnie Garcia MD
Sheri Boyd MD Prasantha Bathini MD
Rahul Bose MD Jason Yoho MD
Mario Rossbach MD Vascular Surgeon
Melanie Morris RN, FNP-C Traci Forrest RN, CNS
Patient Name: ____________________________________________________
Age: _________
DOB: ___________
Gender: M / F
Family doctor: _________________________
Ht: _________
Date: ____________________
Wt: _________ Bra Size: ____________
Other physicians currently treating you: _________________________
Reason for today’s visit: ______________________________________________________________________________
Are you allergic to any medications: ___ No ___Yes _______________________________________________________
(Are you allergic to Shellfish, Iodine or Radiographic Dye): ___No ___Yes
Have you ever been diagnosed with any of the following medical conditions? Check all that apply.
Heart Attack
Atrial Fibrillation
Diabetes
COPD/Emphysema
Coronary Artery Disease
Peripheral Vascular Disease
Thyroid Disorder
Pulmonary Embolism
Congestive Heart Failure
Heart Murmur
Seizure Disorder
Sleep Apnea
High Blood Pressure
Rheumatic Fever
Kidney Disease
Acid Reflux
High Cholesterol
Stroke/TIA
Asthma
Hepatitis A, B or C
Please list any other medical conditions you have been diagnosed with: ______________________________________
________________________________________________________________________________________________
Have you ever had any of the following tests or procedures: Give approximate date if known. Check all that apply.
EKG
Date: _________
Valve Surgery
Date: _________
Treadmill Stress Test
Date: _________
Pacemaker Implantation
Date: _________
Nuclear Stress Test
Date: _________
Defibrillator Implantation
Date: _________
Cardiac Cath
Date: _________
Heart Bypass
Date: _________
Angioplasty (balloon/stents) Date: _________
(How many vessels) ______
Other surgical history (please include approximate dates if known):_______________________________________
______________________________________________________________________________________________
Family History: Please indicate if any of your relatives listed below have a history of:
Heart Attack, Stents, Angioplasty, Bypass Surgery, High Blood Pressure or Cholesterol, Heart Arrhythmia or Stroke.
No Yes If yes, age
Age and Cause
Type of Health Problem(s)
of onset
of Death
Father
Mother
Brother (s)
Sister (s)
List any other IMMEDIATE family members with any of the conditions listed above, include age of onset:
Do you currently use tobacco? __ No __ Yes If yes, what type: __ Cigarettes __ Chewing Tobacco __ Pipe __ Cigars
Do you have a past history of tobacco use? ___ No ___ Yes
If yes, when did you quit: ______________________
Do you drink alcoholic beverages? __ No __ Yes If yes, please list type of alcohol, how often and how much is consumed:
___________________________________________________________________________________________________
Do you use or have you ever used illicit/recreational drugs? __ No __ Yes Comments: _____________________________
PLEASE LIST YOUR MEDICATIONS ON THE MEDICATION SHEET PROVIDED