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Complete this form and bring it with you to your first doctor’s visit.

Patient Information
Patient Name:
Today’s Date:
Referring Physician:
Family Physician:
Date of Birth: Age: 
Height:  ft  in Weight: 
Gender:  female male
Marital Status:  single  married  widowed  divorced
Number of Children:
Personal Health History
What is the reason for this visit?
Have you ever had a heart problem?  Yes  No
If yes, please explain:
Do you have or have you ever had any of the following?
Rheumatic fever Date: 
Heart murmur Date: 
Heart attack Date: 
Chest pain/pressure Date: 
Heart failure Date: 
Rapid heart beat or irregular pulse Date: 
Light-headedness Date: 
Dizziness Date: 
Fainting Date: 
Swelling of the ankles Date: 
Pain in calf muscles when walking Date: 
Congestive heart failure Date: 
Shortness of breath Date: 
Have you ever had any of the following heart studies?
 EKG  Echocardiogram  24 Hour monitor
 Cardiac Catheterization  Treadmill  Chest x-ray
Have you ever had a reaction to the dye used in certain cardiac x-rays?
 Yes  No  I have never had this type of x-ray
Do you have any allergies to medication?  Yes  No
If yes, which medications:
Do you currently smoke?  Yes No Pack per day:
Number of years:
Have you ever smoked?  Yes No Date stoppped:
Do you have elevated cholesterol?  Yes No Last checked:
Do you have high blood pressure?  Yes No How many years:
Do you drink alcoholic beverages?  Yes No How much each day:
Are you generally stressed?  Yes No
Do you drink beverages containing caffeine?  Yes No How much:
Do you excerise?  Yes No
If yes, what is your excerise routine:
Are you following a special diet?  Yes No
If yes, please describe:
Describe your job tasks:
Are you retired?  Yes  No Date 
Are you disabled?  Yes  No Date 
If yes, describe your disability:
Describe any surgeries you have had:
Surgery Year
Please check any other health condition you have or have had in the past:
Scarlet fever Menstrual dysfunction
Anxiety Kidney disease
Emphysema Breathing problems
Ulcer Venereal disease
Anemia Sexual dysfunction
Arthritis Asthma
Stomach or bowel disorder Allergies/Hay fever
Fatigue Gout
Urinary problem Thyroid disease
Rheumatic fever Diabetes/high blood sugar
Depression Migraine headache
Constipation Liver disease
Cancer  Other 
Family History
Do you have a history of heart disease in your family?  Yes  No
If yes, indicate relation and age problems started?
Family Member(s) Alive Deceased Current Age or Age at death Cause of Death