COLUMBIA CARDIAC CARE
New Patient Medical Questionnaire DATE:______
Patient Name: ______DOB:______AGE:______
Primary Care Physician:______City/State: ______
Other Physicians: ______
What physician requested this consultation? ______
CHIEF COMPLAINTWhat Problems are you here for today? ______
______
CARDIAC PROBLEM LISTPlease check any of the following disorders that you HAVE or HAVE HAD, and indicate the year it was first identified.
CARDIAC:
□ Yes □ No Cardimegaly(Enlarged Heart)______□ Yes □ No Coronary Artery Disease______
□ Yes □ No Heart Disease you were born with(congenital)____ □ Yes □ No Heart Failure/Cardiomyopathy______
□ Yes □ No Rheumatic Fever ______□ Yes □ No Arrhythmia/Abnormal Rhythm______
□ Yes □ No Murmer ______□ Yes □ No Previous Cardiac Arrest______
□ Yes □ No Abnormal Heart Valve ______□ Yes □ No Defibrillated/Shocked______
□ Yes □ No Endocarditis(infected heart valve)______□ Yes □ No Pericardial(sac surrounding heart)______
□ Yes □ No Abnormal ECG ______□ Yes □ No Marfan's Syndrome______
□ Yes □ No Angina(heart pain)______□ Yes □ No Hospitalized for cardiac reasons ______
□ Yes □ No Heart Attack______□ Yes □ No Other type of heart disease ______
VASCULAR:
□ Yes □ No Carotid Artery Disease______□ Yes □ No Stroke or TIA (mini-stroke)______
□ Yes □ No Renal(kidney) Artery Disease______□ Yes □ No Any history of aneurysm______
□ Yes □ No Peripheral(leg or arm) Artery Disease ______□ Yes □ No DVT (clots in leg)______
□ Yes □ No Pulmonary embolism (clots in lung) ______□ Yes □ No Other type of vascular Disease______
□ Yes □ No Varicose Veins______
CORONARY RISK FACTORSPlease check any of the following Risk Factors that you have and indicate the year it was first identified.
□ Yes □ No Hypertension (high blood pressure) ______□ Yes □ No Diabetes Mellitus______
□ Yes □ No Abnormal Cholesterol______□ Yes □ No Currently Smoking?______
□ Yes □ No History coronary disease in immediate family? □ Yes □ No Peripheral artery disease?(legs, carotids)__
Father/Brother<55 Mother/Sister<65 □ Low HDL Men<40 Women<50______
□ High Calcium Score______□ High HDL >60______
□ High CRP >3.0______
COLUMBIA CARDIAC CARE
New Patient Medical Questionnaire DATE:______
Patient Name: ______DOB: ______AGE: ______
CARDIAC PROCEDURES/ DIAGNOSTIC TESTING □ Yes □ NoPlease check that you have had or have not had any procedures / diagnostic tests. Write the year and the location of the test in the blank indicated.
Year Location
□ Yes □ No Echo/TEE ______
□ Yes □ No Stress Test (Regular/Nuclear) ______
□ Yes □ No Holter/ Event Monitor ______
□ Yes □ No Carotid Artery/Abdominal Ultrasound ______
□ Yes □ No Heart Catheterization ______
□ Yes □ No Coronary Angioplasty/ Stent Placement ______
□ Yes □ No Peripheral Artery Angiogram/ Angioplasty ______
□ Yes □ No Electrophysiology Study/Ablation ______
□ Yes □ No Pacemaker/ ICD (defibrillator) ______
□ Yes □ No Cardiac Surgery (Bypass/Valve)
Please indicate location/radiation:
o CHEST PAIN/DISCOMFORT
First Occurred: ______
Location:
o Center of chest
o Behind chest bone
o Right side
o Left side
Radiates to:
o Neck
o Shoulder
o Arm
o Jaw
o Upper back
o Upper abdomen
Rating of chest pain:
1 2 3 4 5 6 7 8 9 10 what brings on the pain?
1= very mild 10= very severe o Physical work (e.g. walking)
Duration: o No relation to movement
o Seconds o Come at any time
o 1-5 minutes o after eating
o 5-20 minutes o worse with deep breath
o Hours o Worse with movement
o Days If you use Nitroglycerin:
Type of pain/quality: Relieved in:
o Sharp (needle-like) o 1 minute
o Burning (acidic taste) o 2 minutes
o Discomfort o 10 minutes
o Tightness o No relief
o Weight sensation
o Stabbing
o Squeezing
o Other
oOther:
PLEASE DESCRIBE, IN YOUR OWN WORDS, SYMPTOMS AND THE REASON FOR TODAYS VISIT:______
______
COLUMBIA CARDIAC CARE
New Patient Medical Questionnaire DATE:______
Patient Name: ______DOB: ______AGE: ______
SOCIAL HISTORYMarital Status: □Single □Married □Divorced □Separated □Widowed □Domestic Partner □Previously Widowed
Ethnicity: □ Caucasian □ African American □ Asian American □ Native American □ Hispanic □ Other:______
Number of sons? ______Number of daughters?: ______Current hometown?: ______
Do you have a Medical Power of Attorney? □Yes □No Who? ______Weight: ______Height:______
Advanced Directives?: □None □Do Not Resusciate □Healthcare Proxy □Living Will Date: ______
Are you retired?: □Yes □No Current or Previous Occupation: ______
Primary language? ______Secondary language?______
Leisure activities?: (include any hobbies)______
Home blood pressure monitor? □Yes □No If yes, average readings: ______
Do you use tobacco? □Yes □Formerly □Never
Type: How Much: Start/Quit Dates:
□Cigarettes ______per day Years Smoked?______Quit Date?______
□Cigars ______per day Years Smoked?______Quit Date?______
□Pipes ______per day Years Smoked?______Quit Date?______
□Chewing Tobacco ______per day Years Smoked?______Quit Date?______
Do you use alcohol? □Yes □Formerly □Never
Describe your use?
□Rarely □Social □Daily □Frequently □Occasional □Quit(when)
Type: How much:
□Beer ______cans per day / wk / mo / yr
□Wine ______glasses per day / wk / mo / yr
□Spirits ______glasses per day / wk / mo / yr
Do you use caffeine? □Yes □Formerly □Never
Type:
□Caffeinated Coffee? ______cups per day / wk / mo / yr □Quit(when)______
□ Caffeinated Tea? ______cups per day / wk / mo / yr □Quit(when)______
□ Caffeinated Soda ______cans per day / wk / mo / yr □Quit(when)______
□Chocolate ______servings per day / wk / mo / yr □Quit(when)______
COLUMBIA CARDIAC CARE
New Patient Medical Questionnaire DATE:______
Patient Name: ______DOB: ______AGE: ______
Do you use recreational drugs? □Yes □Formerly □Never
Type: How much: Start/Quit Dates
□Marijuana ______per day / wk / mo / yr When did you start?______Quit? ______Rehab? ______
□Cocaine ______per day / wk / mo / yr When did you start?______Quit? ______Rehab? ______
□Methamphetamine ______per day / wk / mo / yr When did you start?______Quit? ______Rehab? ______
□Other ______per day / wk / mo / yr When did you start?______Quit? ______Rehab? ______
Exercise?
□No/Sedentary □Occasional □Regular □Active Lifestyle □Physically Unable to exercise
Type: How much: Check any applicable:
□Aerobics How long? (Mins.) ______How often?(Per wk)______□Started Exercising
□Cycling How long? (Mins.) ______How often?(Per wk)______
□Dancing How long? (Mins.) ______How often?(Per wk)______
□Jogging How long? (Mins.) ______How often?(Per wk)______
□Running How long? (Mins.) ______How often?(Per wk)______
□Swimming How long? (Mins.) ______How often?(Per wk)______
□Team Sports______How long? (Mins.) ______How often?(Per wk)______
□Walking How long? (Mins.) ______How often?(Per wk)______
□Weights How long? (Mins.) ______How often?(Per wk)______
Please choose the type of diet you are currently on?
Type: How well do you follow:
□Regular
□Low fat/Chol □Strictly □Usually □Occasionally □Non-compliant with diet
□Low salt □Strictly □Usually □Occasionally □Non-compliant with diet
□Diabetic □Strictly □Usually □Occasionally □Non-compliant with diet
□Renal □Strictly □Usually □Occasionally □Non-compliant with diet
□No Added Salt □Strictly □Usually □Occasionally □Non-compliant with diet
□Weight Loss □Strictly □Usually □Occasionally □Non-compliant with diet
□Low Carb □Strictly □Usually □Occasionally □Non-compliant with diet
□Vegetarian □Strictly □Usually □Occasionally □Non-compliant with diet
COLUMBIA CARDIAC CARE
New Patient Medical Questionnaire
DATE:______
Patient Name: ______DOB: ______AGE: ______
CURRENT MEDICATIONS/SUPPLEMENTS □ Yes □ NoPlease list ALL the medications that you are taking at home. Include ALL prescription medications, non-prescription medications, vitamins, herbal remedies and supplements.
Name of Medication Dose/Strength How Many/How Often/When
Example Lasix 40 mg twice a day-morning and night
1) ______
2) ______
3) ______
4) ______
5) ______
6) ______
7) ______
8) ______
9) ______
10) ______
11) ______
12) ______
13) ______
14) ______
15) ______
(Please attach additional pages if necessary)
ALLERGIES / INTOLERANCES TO MEDICATIONS □ Yes □ NoPlease list any medications, or materials you are allergic to, had an adverse reaction to, or do not tolerate and describe the reaction.
Medication Reaction(e.g. hives, swelling, short of breath, rash, etc)
______
______
______
______
______
______
______
______
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COLUMBIA CARDIAC CARE
New Patient Medical Questionnaire DATE:______
Patient Name: ______DOB: ______AGE: ______
PAST MEDICAL HISTORYPlease check any of the following disorders that you HAVE or HAVE HAD, and indicate the year it was first identified.
PULMONARY:
□ Yes □ No Asthma______□ Yes □ No Bronchitis______
□ Yes □ No Emphysema/COPD______□ Yes □ No Tuberculosis______
□ Yes □ No Pneumonia______□ Yes □ No Sleep Apnea______
GASTROINTESTINAL:
□ Yes □ No Reflux(GERD)______□ Yes □ No Hiatal Hernia______
□ Yes □ No Diverticulosis/ Diverticulitis______□ Yes □ No Ulcer______
□ Yes □ No Liver Disease/ Hepatitis______□ Yes □ No Gastritis______
□ Yes □ No Gallbladder Disease/ Gallstones______□ Yes □ No Gastrointestinal Bleed______
RENAL / GENITOURINARY:
□ Yes □ No Dialysis______□ Yes □ No Prostate Disease______
□ Yes □ No Kidney Stones______□ Yes □ No Kidney Disease/ Elevated Creatinine______
NEUROLOGICAL/ PSYCHOLOGICAL:
□ Yes □ No Intracranial (in the brain) Bleeding______□ Yes □ No Seizure Disorder______
□ Yes □ No Migraine Headaches______□ Yes □ No Dimentia______
□ Yes □ No Depression/Anxiety______□ Yes □ No MS______
□ Yes □ No CVA/Stroke/TIA______
FEMALE REPRODUCTIVE: □Not Applicable
□ Yes □ No Multiple miscarriages______□ Yes □ No Currently Pregnant(number of weeks?)____
□ Yes □ No Menopause(at what age?)______
ENDOCRINE:
□ Yes □ No Thyroid Disorder ______□ Yes □ No Diabetes______
OTHER:
□ Yes □ No Anemia______□ Yes □ No Bleeding Disorder______
□ Yes □ No Clotting Disorder______□ Yes □ No Gout______
□ Yes □ No Arthritis______□ Yes □ No Ambulate with assistance______
□ Yes □ No HIV______□ Yes □ No Previous weight Loss meds(i.e Fen Phen)___
□ Yes □ No Reaction to iodine contrast______□ Yes □ No Previous exposure to iodine contrast
□ Yes □ No Vertigo______□ Yes □ No Cancer (type?)______
□ Yes □ No Autoimmune Disorders(i.e. Lupus)______
Past Medical History:Please list any other health problems that are not on the list:
______
SURGICAL HISTORY/ OPERATIONS □ Yes □ NoPlease list any surgeries you have had and include the year and location.
Surgery Date Surgeon Location
Example: Gallbladder Removed 1980 Dr. Frank Smith Parkland, Dallas
______
______
Labs: □Yes □No If yes Date:______Quest///Labcorb///Other lab:______
Radiology services: CT///MRI///MRA///EBCT scan (calcium score) X-Ray///Ultrasound///Other:______
When:______Where:______
Family History: □ AdoptedPlease indicate below if your FATHER, MOTHER, SIBLING(S), or CHILDREN have ever been diagnosed with any of the following conditions, by writing the age (not a check mark!) at which the condition first occurred in the appropriate box. PLEASE NOTE: If there is no history of these conditions or if they are unknown, THEN check the NONE or Unknown box in the appropriate column.
Condition / Father / Mother / Sister(s) / Brother(s) / Child(ren)Angina
Heart Attack
Angioplasty
Heart Surgery
Abnormal Heart Rhythm
Sudden/Unexpected Death
Stroke/ TIA (mini stroke)
Blood Clots
Heart failure/ Cardiomyopathy
Aneurysm
None of the above
Unknown
Current age
Deceased age
Other family members (aunts, uncles, cousins, grandparents) with heart Problems:
______
COLUMBIA CARDIAC CARE
New Patient Medical Questionnaire
Review of Systems:Please Check “Yes” or “No” in the box to indicate if you are experiencing or have experienced any of the following signs or symptoms in the last three months.
CONSTITUTIONAL: YES NO CARDIAC: YES NO
Significant Weight loss □ □ Chest pain □ □
Significant Weight Gain □ □ Chest pressure □ □
Shortness of Breath □ □
ENMT: Difficulty breathing while lying flat □ □
Excessive Snoring YES NO Awakening with breathing difficulty □ □
□ □ swelling in feet/ ankles □ □
Palpitations □ □
RESPIRATORY: Nearly passing out spells □ □
Coughing up blood YES NO Passing out spells □ □
□ □
GASTROINTESTINAL: YES NO Any other reason as to why you need to see a cardiologist?
______
Blood in Stools (Black stools) □ □ ______
______
GENITOURINARY: YES NO ______
Blood in urine □ □ ______
ED □ □ ______
______
VASCULAR: YES NO ______
Calf pain with walking □ □ ______
MUSCULOSKEKETAL: YES NO
Muscle pain at rest □ □
NEUROLOGICAL: YES NO
Dizziness □ □
PSYCHIATRIC: YES NO
Excessive Stress □ □
ENDOCRINE: YES NO
Feel cooler than others □ □
Patient signature:______
HEMATOLOGICAL: YES NO Dr. Chowdhry’s Signature:______
Unusual bleeding □ □ Imtiaz H. Chowdhry, M.D. F.A.C.C.
Thank you for taking the time to complete this
Questionnaire!