First Name
E-Mail
CARDIAC MEDICAL HISTORY QUESTIONNAIRE
Address
Last Name
City
State
Zip
Country
Phone # (if none, put none)
Date of Birth
Procedures Requested
Height
Gender
Weight
Do you smoke?
Please Check all that Apply:
Addiction to alcohol or drugs
Arthritis
Asthma/Breathing Problems
Autoimmune
Bleeding Problems / Blood Clots
Blood Disorders
Cancer
Cardiac Arrhythmia (rapid heart rate)
Chronic Pancreatitis
Cirrhosis of the Liver
Exposure to Tuberculosis
Gallstones
Heart Murmur
Hepatitis
Heart or Vascular disease
High Blood Pressure, Coronary Artery Disease or Circulatory conditions
HIV or AIDS
Hypertension/ High Blood Pressure
Metabolic Conditions. (i.e. hypothyroidism)
Previous reactions to Anesthesia Clots
Seizures or Epilepsy
Sleep Apnea
Stroke
Thromboembolism
Do you have any medical condition that you have been told would disqualify you for any type of medical procedure or surgery?
Do you have special needs that need accomodation? (dietary, sensory, handicap, etc)
Do you have any other medical condition that you are aware of that is not listed above?
Your Medical Provider
How long have you had this condition?
What have you done to try to alleviate your condition and what were the results?
Please list all previous surgeries or hospitalizations
Please list all allergies
How did you hear about us?
Chronic, Long term Steriods (past or present)
If you said yes to any above, please explain
When were you diagnosed?
Current Medications and Supplements:
Kidney Diseases
Hernia
Type 2-Diabetes
Do you use a walking device?
Please describe your current symptoms and level of pain/weakness/tingling/numbness with corresponding normal activities?
Do we have permission to contact?
Provider Contact #
Multiple Sclerosis (MS) under symptoms
Do you have a current Doppler or Angiogram/Venogram?
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