Healthy Hearts Patient History

• Please choose your office*
  • ENCINO
  • MISSION HILLS
  • VALENCIA
  • WESTWOOD
• FULL NAME
• DATE
  MM slash DD slash YYYY
• AGE
• DOB
  MM slash DD slash YYYY
• HEIGHT
• WEIGHT
• Marital Status
  • Single
  • Married
  • Widow
  • Divorced
  • Separated
• OCCUPATION
• HOW DID YOU HEAR ABOUT US
• REFERRING PHYSICIAN 1
• REFERRING PHYSICIAN 2
• REASON FOR CONSULTATION 1
• REASON FOR CONSULTATION 2
• REASON FOR CONSULTATION 3
• PREVIOUS DIAGNOSIS OF HEART DISEASE
  • YES
  • NO
• IF YES PLEASE ELABORATE 1
• IF YES PLEASE ELABORATE 2
• IF YES PLEASE ELABORATE 3
• IF YES PLEASE ELABORATE 4
• CHEST PAIN
  • YES
  • NO
• SHORTNESS OF BREATH
  • YES
  • NO
• PALPITATIONS
  • YES
  • NO
• SWELLING OF ANKLES
  • YES
  • NO
• DIZZINESS – SYMPTOM
  • YES
  • NO
• FAINTING
  • YES
  • NO
• HEART MURMUR
  • YES
  • NO
• HIGH BLOOD PRESSURE
  • YES
  • NO
• HIGH CHOLESTEROL
  • YES
  • NO
• DIABETES
  • YES
  • NO
• HEART ATTACK
  • YES
  • NO
• STROKE
  • YES
  • NO
• LAST ELECTROCARDIOGRAM DATE
  MM slash DD slash YYYY
• LAST ELECTROCARDIOGRAM
  • NORMAL
  • ABNORMAL
• LAST CHEST X-RAY DATE
  MM slash DD slash YYYY
• LAST CHEST X-RAY
  • NORMAL
  • ABNORMAL
• LAST TREADMILL TEST DATE
  MM slash DD slash YYYY
• LAST TREADMILL
  • NORMAL
  • ABNORMAL
• PRIOR CARDIAC PROCEDURES 1
• PRIOR CARDIAC PROCEDURES 2
• PRIOR CARDIAC PROCEDURES 3
• PRIOR CARDIAC PROCEDURES 4
• PRIOR CARDIAC PROCEDURES COMPLICATIONS 1
• PRIOR CARDIAC PROCEDURES ANY COMPLICATIONS 2
• DESCRIBE ANY OTHER MEDICAL CONDITIONS OR DIAGNOSES 1
• DESCRIBE ANY OTHER MEDICAL CONDITIONS OR DIAGNOSES 2
• DESCRIBE ANY OTHER MEDICAL CONDITIONS OR DIAGNOSES 3
• PRIOR NON-CARDIAC PROCEDURES 1
• PRIOR NON-CARDIAC PROCEDURES 2
• PRIOR NON-CARDIAC PROCEDURES 3
• PRIOR NON-CARDIAC PROCEDURES 4
• PRIOR NON-CARDIAC PROCEDURES ANY COMPLICATIONS 1
• PRIOR NON-CARDIAC PROCEDURES ANY COMPLICATIONS 2
• SMOKING HABITS
  • NEVER A SMOKER
  • PREVIOUS SMOKER
  • CURRENT SMOKER
• Current smoker Quantity
• ALCOHOL HABITS
  • YES
  • NO
• DESCRIBE ALCOHOL
• EXCERCISE HABITS
  • YES
  • NO
• DESCRIBE EXCERCISE
• COFFEE HABITS
  • YES
  • NO
• DESCRIBE COFFEE
• SPECIAL DIET HABITS
  • YES
  • NO
• DESCRIBE SPECIAL DIET
• FATHER – IF LIVING AGE
• FATHER – HEALTH
• FATHER – IF DECEASED AGE
• FATHER – CAUSE OF DEATH
• MOTHER – IF LIVING AGE
• MOTHER – HEALTH
• MOTHER – IF DECEASED AGE
• MOTHER – CAUSE OF DEATH
• BROTHERS – IF LIVING AGE
• BROTHERS – HEALTH
• BROTHERS – IF DECEASED AGE
• BROTHERS – CAUSE OF DEATH
• SISTER – IF LIVING AGE
• SISTER – HEALTH
• SISTER – IF DECEASED AGE
• SISTER – CAUSE OF DEATH
• WEIGHT GAIN
  • YES
  • NO
• lbs. GAIN
• WEIGHT LOSS
  • YES
  • NO
• lbs. LOSS
• RESPIRATORY COUGH
  • YES
  • NO
• RESPIRATORY SLEEP APNEA
  • YES
  • NO
• ABDOMINAL PAIN
  • YES
  • NO
• CONSTIPATION
  • YES
  • NO
• PAINFUL URINATION
  • YES
  • NO
• INCREASED FREQUENCY
  • YES
  • NO
• JOINT PAIN
  • YES
  • NO
• HEADACHE
  • YES
  • NO
• DIZZINESS
  • YES
  • NO
• Do your legs ever feel tired, causing you stop and rest?
  • YES
  • NO
• When you walk do you ever have to stop because you have pain or cramping in your calves or thighs?
  • YES
  • NO
• Do you ever experience cramping, tightness, "Charlie Horses" or pain in the legs and feet when lying down that improves when you stand up?
  • YES
  • NO
• Has anyone ever told you that you have poor circulation in your legs, intermittent claudication or periheral arterial disease?
  • YES
  • NO
• DRUG 1
• DOSAGE & FREQUENCY 1
• DATE FIRST PRESCRIBED 1
• PHYSICIAN 1
• DRUG 2
• DOSAGE & FREQUENCY 2
• DATE FIRST PRESCRIBED 2
• PHYSICIAN 2
• DRUG 3
• DOSAGE & FREQUENCY 3
• DATE FIRST PRESCRIBED 3
• PHYSICIAN 3
• DRUG 4
• DOSAGE & FREQUENCY 4
• DATE FIRST PRESCRIBED 4
• PHYSICIAN 4
• DRUG 5
• DOSAGE & FREQUENCY 5
• DATE FIRST PRESCRIBED 5
• PHYSICIAN 5
• DRUG 6
• DOSAGE & FREQUENCY 6
• DATE FIRST PRESCRIBED 6
• PHYSICIAN 6
• DRUG 7
• DOSAGE & FREQUENCY 7
• DATE FIRST PRESCRIBED 7
• PHYSICIAN 7
• DRUG 8
• DOSAGE FREQUENCY 8
• DATE FIRST PRESCRIBED 8
• PHYSICIAN 8
• DRUG ALLERGIES
  • YES
  • NO
• DRUG ALLERGIES COMMENTS
• IODINE OR CONTRAST AGENTS
  • YES
  • NO
• IODINE OR CONTRAST COMMENTS
• OTHER ALLERGIES
  • YES
  • NO
• OTHER ALLERGIES COMMENTS
• NUMBER OF CHILDREN
  Please enter a number less than or equal to 20.
• NUMBER OF PREGNANCIES
  Please enter a number less than or equal to 20.
• MENOPAUSE
  • YES
  • NO