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