PRE-VISIT FORM
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
Other:
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:
Occupation:
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
Mother
Father
Sister(s)
Brother(s)