Name:_________________________ Age: _____________ Date: ___________________________
Who is your Primary Care Physician? _________________________________________________
What is the reason for your referral? __________________________________________________
Are you currently enrolled in a Hospice program or any type of Skilled Nursing Facility? ________
If so, please list the facility and the date you were enrolled. ________________________________
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PLEASE CHECK IF YOU HAVE OR HAD ANY OF THE FOLLOWING:
_____ Heart Attack
_____ Heart Failure
_____ Coronary Artery Disease
_____ Coronary Angioplasty or Stent
_____ Heart Murmur
_____ Pacemaker
_____ Stroke
_____ High Blood Pressure
_____ Infective Endocarditis
_____ Blood Clots
_____ Diabetes Mellitus
_____ Shortness of Breath
_____ Pneumonia
_____ Sarcoidosis
_____ Bleeding Problems
_____ Bleeding Ulcers
_____ Hiatal Hernia
_____ Temporary Blindness
_____ Varicose Veins
_____ Kidney Failure
_____ Difficulty Urinating
_____ Weight Loss
_____ HIV Positive
_____ Heart Surgery
_____ Angina/Chest Pain
_____ Heart Catheterization
_____ Echocardiogram
_____ Childhood Heart Ailment
_____ Valvular Heart Disease
_____ Rheumatic Fever
_____ Fainting/Dizzy Spells
_____ Palpitations (heart racing
_____ Leg Pain While Walking
_____ Thyroid Problems
_____ Asthma/Emphysema
_____ Tuberculosis
_____ Anxiety or Panic Attacks
_____ Anemia
_____ Leg/Ankle Swelling
_____ Gallbladder Problems
_____ Coughing Spells
_____ Cancer
_____ Kidney Stone/Infections
_____ Aneurysm
_____ Weight Gain
_____ Hepatitis
Do you have any other condition not listed above?_______________________________________
Do you Smoke? ____________________ How many packs per day? _______________________
For how many years? _______________ When did you quit? _____________________________
Do you use alcohol? ________________ How much? ____________________________________
Are you pregnant? __________________________________________________________________
List your allergies: __________________________________________________________________
Are you allergic to any of the following?
____X-ray or contrast dye ____ Iodine ____ Shrimp/Shellfish/Seafood ____ Local Anesthetics
List your medications & doses:___________________________________________________________
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