Patient Health History Form
Franklin County Cardiovascular Associates
Department of Cardiology
Name: ________________________________________ Date of Birth: ___________ Date _____________
Referring Physician:
Reason for your visit:
Date of visit:
Please indicate if you are having or have had any of these problems in the past
Circle= YES Cross out =No
cont.
Catheterization
PTCA/Stent
CABG
Pacemaker
Other Heart Procedure:
Constitutional:
HEENT:
Fatigue
Fever
Night Sweats
Weakness
Recent Weight Loss/Gain
Nose Bleeds
Blurred Vision
Ringing in Ears
Difficulty eating or
swallowing
Endocrine:
Gastrointestinal:
Hematological/Lymphatic:
Musculoskeletal:
Thyroid Disease
Diabetes
Heat/Cold Intolerance
Hormone Therapy
Nausea/Vomiting
Reflux/Heartburn
Diarrhea/Constipation
Anemia
Easy Bruising
Muscle Cramps
Joint Swelling
Extremity Swelling
Pain to legs with walking
Neurological:
Psychiatric:
Respiratory:
Skin:
Fainting
Seizures
Visual Changes
Extremity weakness
Numbness or tingling
Stroke
Anxiety
Depression
Memory Loss/Confusion
Asthma
COPD
Cough
History of Pneumonia
Emphysema
Other: ___________
Sores/Lesions
Itching
Rashes
Bruising
Genitourinary:
Sleep Habits:
Snoring
Sleep Apnea
Cardiovascular:
Chest Pain
Palpitations
Heart Murmur
Hypertension
Shortness of Breath
Heart attack (MI)
Frequent Urination
Painful Urination
Difficulty/No erection
(men)
Do you have any allergies or sensitivities to medication or food? Please tell us what and the symptoms.
Any allergic reactions to Latex, Tap, IV dye?
Current Medications:
Name:
Dose:
# times/day:
Name:
Dose:
# times/day:
Hospitalizations (including operations):
Year:
Reason:
Have you ever been told you had (please circle)
•Hypertension (yes/no) •Diabetes (yes/no)
Hospital:
•High Cholesterol (yes/no)
Physician:
•Stroke (yes/no)
Are your parents alive (yes/no) If alive, how old are they? ________________________
If not alive, how old were they when they passed away and what was the cause of death?
Mother:
Father:
How many siblings do you have: ________
Are they all alive: (yes/no) If no, what were the ages and cause of death: _______________________
Family History - Has any of your immediate family members had: (mother, father, sister, brother)
Heart Attack: Yes _____ No _____
Who and at what age? ___________________________
Stroke: Yes _____ No _____
Who and at what age? ___________________________
Heart Rhythm Problems: Yes ____ No ____ Who and at what age? ___________________________
Sudden Death: Yes ____No ____
Who and at what age? ___________________________
Social History:
Material status:
Single Married Divorced Widowed Significant Other
Live with: __________________
How many children do you have? _____ What are their ages?
If not alive, what was the cause of death? ________________________________________________
Do any of your children have illness (yes/no) If yes, what illness? ____________________________
Do you smoke?
How many packs per day?
How long?
Were you ever a smoker?
If yes, for low long?
Years as a Nonsmoker:
When did you quit?
Do you drink alcohol?
How many?
Per day
Per week
Do you use recreational Drugs?
If yes, what kind?
Occupation:
Do you do any regular exercise?
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