RICHARD L. MUELLER, MD, PC FORM #2

CARDIOVASCULAR DIAGNOSTICS, PC / MEDICAL ASSOCIATES OF NEWYORK

401 EAST 55th STREET, NEW YORK, NY 10022-6158

NAME (please print):DATE:

CARDIOLOGY PATIENTS – NEW & FOLLOW UP:

ARE YOU HAVING ANY OF THESE SINCE YOUR LAST VISIT? (& for all new patients)

CHEST PAIN / PRESSURE / HEAVINESS / DISCOMFORT? Y N PALPITATIONS / RACING HEART? Y N

FAINTING? Y NDIZZINESS?Y NSHORTNESS OF BREATH? Y N

HOW OFTEN? WHEN DID SYMPTOMS START?

IF ANY SYMPTOMS, PLEASE LIST DETAILS:

HOW LONG DOES CHEST PAIN/PRESSURE / DISCOMFORT OR PALPITATIONS LAST FOR THE LONGEST CONTINUOUS PERIOD? (SECONDS, MINUTES, HOURS, DAYS) IS THE DISCOMFORT SHARP OR DULL?

DISCOMFORT OR SHORTNESS OF BREATH OCCURS WITH EXERTION OR RANDOMLY?

HOW MUCH EXERTION BRINGS IT ON?

DOES CHEST DISCOMFORT TRAVEL TO JAWS / ARMS / NECK / BACK?

IS DISCOMFORT ASSOCIATED WITH NAUSEA, SWEATING, OR SHORTNESS OF BREATH?

IF YOU PRESS ON CHEST WHERE DISCOMFORT OCCURS (EVEN IF NOT NOW), CAN YOU RECREATE THE SYMPTOMS? Y N

DOES ANYTHING MAKE THE CHEST DISCOMFORT BETTER? ANTACIDS?WORSE LYING DOWN? DEEP BREATH?

ANY DIZZINESS OR FAINTING WITH THE PALPITATIONS?

DIZZINESS: DOES IT OCCUR ONLY WITH STANDING? ANY VERTIGO (SKY OR CEILING SPINNING)?

ANY ASSOCIATED NAUSEA OR SWEATING OR PALPITATIONS (specify)?

WHAT EXACTLY WHERE YOU DOING JUST BEFORE ANY FAINTING OCCURRED?

WAS THERE ASSOCIATED NAUSEA, SWEATING, HEAD RUSH, OR FEELING DETACHED?

VEIN PATIENTS ONLY - NEW & FOLLOW UP:

PRIOR PROCEDURES / YEAR: VEIN CLOSURESURGERYSCLEROTHERAPY / EXTERNAL LASER

Hole in the Heart ? Migraines ? Allergy to lidocaine / novocaine Seizures? Stroke ? Blood Clots / Thick Blood ? Liver/Kidney Disease Asthma:

OCCUPATION (mandatory for insurance coverage):

Have you worn compression stockings? How Long? Knee High / Thigh High

Taking Tylenol / aleve / ibuprofen for vein leg pain ? If so, how many times per week ?

Family history of deep venous thrombosis / blood clots, pulmonary embolism, varicose veins:

ARE YOU HAVING ANY OF THESE VEIN SYMPTOMS SINCE YOUR LAST VISIT? (& for all new patients)

(please circle): Pain Aching Heaviness Itching Burning Numbness Night Cramps Restless Legs

Crawling Sensation Heat Ankle Swelling Foot Swelling Bleeding Veins Skin Ulcers / Open Sore New Veins

Darkening of Skin Rash / Eczema Skin Thickening Veins on Abdomen, Genitals, or Buttocks Abdominal Cramps

Do Your Vein Symptoms Limit Your Activities ? Y / N How So?

Do They Limit Your Work Life? Y / N How So?

Limit Household Life? Y / N Details: Limit Leisure Life? Y / N Details:

Do You Have to Stop & Rest or Elevate Legs? Y / NHow Often:

SIGNATURE REVIEWING PHYSICIAN: DATE:

Circle / Mark: Richard L. Mueller, MD David Mack, MD

I have personally reviewed this History & Review of Systems with the patient. Any unchecked item is No, None, or Declined to Answer. Page 1

FORM #2

NAME (please print):DATE:

Since your last visit, are there are updates to the following Medical History?

Symptoms or Abnormalities in Any Body Function:

Medications:

Physicians caring for you:

Hobbies / Activities:

Alcohol / Tobacco / Drug Use:

Marital Status:

Occupation:

Allergies & Adverse Reactions to Medications:

SIGNATURE/REVIEWINGPHYSICIAN DATE:

Circle / Mark: Richard L. Mueller, MD David Mack, MD

I have personally reviewed this History & Review of Systems with the patient. Any unchecked item is No, None, or Declined to Answer. Page 2