Microsoft word - important checklist to be completed before your appointment - 8.12

FORM 4, PATIENT INFORMATION FORM
Tri-City Cardiology Consultants, P.C.
Dobson Baywood Mtn Vista S. Gilbert Ironwood Patient Name: ___________________________________________________________ Date of Visit:________________ Date of Birth: ________________ Age:___________ Sex:__________ Height:____________ Weight:____________lbs.
Referring Doctor:___________________________________ Primary Care Doctor:_________________________________ Reason for Visit (current symptoms today):___________________________________________________________________ Recent hospitalization? If yes, please explain:_________________________________________________________________ Drug/Food Allergies
Are you allergic to any medications:
Other allergies (food, adhesive tape, iodine, latex, etc.):
Current Medications (please list all prescription, non-prescription, vitamins and nutritional supplements)
Local Pharmacy (name & crossroads):_____________________________________ Phone: ( )________-____________ Mail Order Pharmacy:___________________________________________________ Fax: ( )_________-____________ Risk Factors
Do You Use Tobacco: Current Former Never If former, Year Quit:_______________
If Yes, Type: Chewing Cigarettes Pipe Smokeless
Packs/day______________
Have you ever been diagnosed or are taking medications for the following conditions:
Diabetes: Yes No
Unknown If Yes, Type: Type 1 (Juvenile) Type 2 (Adult onset) Year diagnosed____________
High Cholesterol: Yes No Unknown
If Yes, Type: Cholesterol Triglycerides Cholesterol+Triglycerides Low HDL Syndrome
High Blood Pressure: Yes No Unknown Year diagnosed______________
Family History of Heart Disease(CAD) prior to age 55: Yes No Unknown Adopted (No Fam Hx Unknown)
Peripheral Vascular Disease (poor circulation in legs): Yes No Unknown
Social History
Marital Status: Divorced Married Single Widowed Life Partner Other:_________________________
Do you have children: No Yes If Yes, Number of sons:_____________ Number of daughters:______________
White Black/African American Hispanic/Latino American Indian/Alaska Native Asian Pacific Islander/Native Hawaiian Other __________________________ Refused (declined) Do you follow a specific Diet: (check all that apply)
Diabetic Low Carb Low Fat, Low Chol Low Salt No Added Salt No specific diet Regular Renal Vegetarian Weight loss Other:________________________ Activity Level (exercise): Sedentary Occasional Regular Active Life Style Physically Unable to Exercise
Exercise Type: (check all that apply)
Frequency:_________________(times per week)
Aerobics Cycling Dancing Elliptical Jogging Physical Therapy Running Swimming Team Sports Walking Weight lifting Other:_______________________________________ Do you consume Alcohol: Yes No Former If Yes, What Type: Beer Wine Liquor
If Yes, Frequency: Rarely Frequently Social Occasional Daily Drinks per week:______________
Do you consume Caffeine on a daily basis: Yes No Cups per day:___________________
If Yes, What type: Chocolate Coffee Energy Drink Soda Tablets Tea Other:_____________________
Drug use/Abuse: Yes No Former If Yes, What type:_________________________________
Advanced Directives: None DNR HC Proxy Living Will
Primary Language: English Spanish Other:__________________________________
Family History
Unknown- (Unknown)Family Hx
Place a check mark in the box for any conditions below that apply: Adopted - (Unknown)Family Hx
RELATIONSHIP
TO PATIENT:
_________
CURRENT AGE:
AGE AT DEATH:
HEART ATTACK:
ARRHYTHMIA:
HEART FAILURE:
ANEURYSM:
STROKE(CVA):
HIGH BLOOD
PRESSURE:
CHOLESTEROL:
DIABETES:
LUNG DISEASE:
RENAL DISEASE:
Type:____________
Other pertinent family history:
Past Medical History
Place a check mark in the box for any of the conditions that apply: Respiratory: COPD Pulmonary Embolus Pulmonary Hypertension Sleep Apnea Other:______________________
Renal: End Stage Renal Disease Renal Artery Stenosis Renal Insufficiency Other:__________________________
Endocrine: Hyperthyroidism Hypothyroidism Obesity Other:_______________________________________
Oncology: Breast Cancer Skin Cancer Lung Cancer Prostate Cancer Other:________________________
Chemotherapy Radiation Other:_________________________________________________________ Cardiac: Arrhythmias Congestive Heart Failure CAD Heart Attack (MI) Valvular Heart Disease
CABG (Bypass) Coronary Stent ICD Pacemaker PTCA (Angioplasty) Other:___________________________ Vascular: Abdominal Aneurysm Peripheral Arterial Disease Carotid Disease DVT Thoracic Aneurysm
Varicose Veins Amputation Aneurysm Repair Vein Stripping Other:____________________________ List any other medical conditions:
List any other surgeries:
Cardiac Testing
Echo (ultrasound):
Electrophysiology:
Cath Lab:
Vascular:
Stress Test:
Other:
___________________________
Any other cardiac testing:
Review of Symptoms
Check only the problems you are currently experiencing: Cardiac:
Vascular:
Constitutional:
Respiratory:
Gastrointestinal:
Genitourinary:
Neurology:
Psychiatric:
Hematologic:
Endocrine:
Derm(Skin):
Musculoskeletal:
Any additional symptoms you are experiencing:
Patient Name (printed):

Important checklist to be completed before your appointment - 8.12

Form 1 Directions and Maps - 5.12

FORM 2 Communication Tips - 3.12

FORM 3 Important message about your visit - 3.12

Form 5 Important Message Regarding Our Financial Policy Signature Line - 8.12

FORM 6 Authorization to Release Health Information - 5.12

FORM 7 Authority to Release Private Health Information - 5.12

Notice of Privacy Practices 2013

FORM 10 Peripheral Vascular Health Screening Questionnaire - 11.10

FORM 11 Important message about managing your medications - 11.10

Source: http://www.tricitycardiology.com/wp-content/uploads/2013/09/PatientInformationForm.pdf