Patient Information
NAME:_______________________________________________________________________________
LAST
FIRST
MI
ADDRESS:___________________________________________________________________________
STREET
APARTMENT NUMBER
_________________________________________________________________________________________
CITY
STATE
ZIP CODE
HOME PHONE: ______________________CELLULAR PHONE______________________________
MARITAL STATUS: (CIRCLE ONE)
SINGLE
MARRIED
WIDOW
DIVORCED
REFERING PHYSICIAN:_____________________________________________________________
(If no referring Physician, how did you find out about Dr. Rajeev)______________________________
PRIMARY PHYSICIAN: _____________________________________________________________
DATE OF BIRTH:___________________SOCIAL SECURITY#:_____________________________
PRESENT EMPLOYER:______________________________________PHONE:__________________
SPOUSE’S NAME:_______________________________
SPOUSE’S DATE OF BIRTH:________________________SS#______________________________
EMERGENCY CONTACT NAMES & NUMBERS:________________________________________
_____________________________________________________________________
Please give your insurance cards to the receptionist.
PRIMARY INSURANCE:________________________________________________________
INSURED’S NAME:_________________ INSURED’S DATE OF BIRTH:________________
INSURED’S ADDRESS (IF DIFFERENT FROM PATIENT’S ADDRESS):________________
_______________________________________________________________________________
SECONDARY INSURANCE:_____________________________________________________
INSURED’S NAME:__________________ INSURED’S DATE OF BIRTH:_______________
INSURED’S ADDRESS (IF DIFFERENT FROM PATIENT’S ADDRESS):_______________
________________________________________________________________________
HEALTH QUESTIONAIRE
Name:________________________________________
Date of Birth: __________ Phone Number:__________
Medical History:
What health problems do you have or have you ever had? (circle all that apply to you)
previous heart attack
pacemaker
diabetes
heart failure
high cholesterol
previous angioplasty/stent
arrhythmia
stroke
cardiac arrest
coronary disease
previous bypass surgery
peripheral vascular disease
headaches
emphysema
asthma
ulcer
hypertension
kidney disease
carotid disease
liver disease
heart valve disease
blindness
colitis
arthritis
nerve loss
rheumatic fever
chronic bronchitis
glaucoma
depression
TIAs
cancer
reflux disease
thyroid disease
anxiety disorder prostate disease
Previous cardiac evaluation:
Have you ever had an EKG? Y / N
Where? _________________________________________________________________
Have you ever had a stress test? Y / N
Where? _________________________________________________________________
Have you ever had a heart catheterization? Y / N
Where? _________________________________________________________________
Have you ever had an echo of your heart? Y / N
Where? _________________________________________________________________
Physicans:
Have you ever been treated by a cardiologist? Y / N
Name? _________________________________________________________________
Cardiologist’s Phone__________________ Location_____________________________
Primary doctor___________________________________ Phone__________________
Allergies:
Are you allergic to any medications? N / Y
Which ones and what reaction?
________________________________________________________________________
________________________________________________________________________
Are you allergic to iodine, shellfish, seafood? Y / N
Local anesthetics? Y / N
Social History:
Do you currently smoke? Y / N How many packs/day? ______ How many years?_____
Do you use alcohol? Y / N How often? _______________________________________
Are you pregnant or think you MIGHT be pregnant?
No / Yes
Family History:
Do you have any family members who had heart attacks younger than age 55?
Y/N
Do you have any family members who had heart disease?
Y/N
Do you have any family members with diabetes? Y / N
High blood pressure? Y / N
What health problems does/did your mother have? ______________________________
If deceased, date of death: __________
What health problems does/did your father have? _______________________________
If deceased, date of death: __________
Diet:
Do you have high cholesterol?
Y/N
Do you adhere to a low cholesterol/ low fat diet?
Y/N
Do you take any medicines/supplements not prescribed by a physician?
Y/N
Do you salt your foods?
Y/N
Circle any of the following symptoms you currently experience:
Body System
Vision:
Ears, Throat:
Cardiac:
Cardiac:
Lungs:
Abdomen/GI:
ID:
Endocrine:
Skin:
Psych:
Neuro:
Musculoskel:
Heme:
Allerg/Immuno:
Symptom
Blurry vision
Swollen glands
Chest pain/pressure
Skipped beats
Wheezing
Abdominal pain
Night sweats
Excessive thirst
New moles
Depression
Headache
Leg pain at rest
Bruising
Hay fever
Double vision
Pain on swallowing
Palpitations
shortness of breath on exertion
Cough
Reflux/indigestion
Fevers
Excessive urination
Non-healing leg/foot ulcers
Nervousness
Tingling/numbness
Leg pain after walking
Tiny blood spots
Skin rash
Eye pain
Hearing loss
Difficulty sleeping flat
Swollen ankles
Pain with breathing
Nausea/vomiting
Dark sputum
Weight gain
Hair loss
Anxiety
Loss of feeling in legs
Fatigue
Pale colored skin
Drug allergy
Health Insurance Portability and
Accountability Act Disclosure
In service to our patients, Heart and Vascular Care of Georgia strives to comply with all
applicable state and federal laws and regulations.
As part of this commitment to our patients, we abide by the Health Insurance Portability
and Accountability Act.
Under this Act we will always strive to minimize the disbursement of any of your private
information and we will act to protect your privacy as our patient. Your private information will
only be used for all purposes related to your medical care including treatment, payment, and
health care operations.
__________________________
Patient Name
__________________________
Date
Heart and Vascular Care of Georgia
505 Jenkins street, La Grange,
GA, 30240
Tel:(706) 407-0161,
Fax:(706) 756-1404,
Authorization for the Release of Patient Information
___ I DO NOT wish to have test results or other medical information released to any person
other than myself.
___ I DO wish to have test results or other medical information released to the following
person(s).
Name____________________Relationship________________Phone_____________
Name____________________Relationship________________Phone_____________
Name____________________Relationship________________Phone_____________
It is the responsibility of the patient to notify this office of any changes in the above information.
If changes do occur, the patient must file another Authorization of Release of Patient Information
with this clinic.
Please understand that it may be necessary for us to disclose some or all of the information
contained in your medical records to other physicians, nurses, and/or healthcare providers
(collectively referred to as “providers). At times, other providers assist us in assessing a
patient’s condition, screening for potential problems, or providing consultation under certain
circumstances. All healthcare providers are required by law to maintain your patient
confidentiality.
Also, due to the increased awareness of quality care and outcomes measurements, it may be
necessary to disclose information regarding you care to healthcare agencies (both private and
governmental), your insurance company and/or your self insured employer. Regarding the
information going to your employer, other than information needed to verify your insurance
coverage the data released will consist of statistical information only.
Patient Signature_______________________________Date______________________
Printed Name__________________________________SS#______________________
Witness_______________________________________