Cottage Grove Cardiology, PC

Cottage Grove Cardiology, PC

Patient Name: ______Date: ______

Please bring information to your appointment

Cardiac (Heart Problems)

Hepatic ( Liver Problems) Endocrine

Jaundice / Yes ( ) No( )
Hepatitis A, B or C / Yes ( ) No ( )
Cirrhosis / yes ( ) No( )
Elevated Enzymes / Yes ( ) No( )
Diabetes / Yes ( ) No ( )
Thyroid / Yes ( ) No ( )

Renal (Kidney Problems)

Insufficiency / Yes ( ) No ( )
Chronic Failure / Yes ( ) No ( )
Dialysis / Yes ( ) No ( )

Immune System Cancer

HIV/Aids / Yes ( ) No ( )
Colon / Yes ( ) No ( )
Breast / Yest ( ) No ( )
Other if yes, where

Gastroenterology/Stomach

Constipations / Yes ( ) No ( )
Diarrhea / Yes ( ) No ( )
Trouble Swallowing / Yes ( ) No ( )
Colon Polyps / Yes ( ) No ( )
Colitis/Crohn;s / Yes ( ) No ( )
Diverticulosis / Yes ( ) No ( )
Ulcers / Yes ( ) No ( )
Gallstones
/ Yes ( ) No ( )

Cottage Grove Cardiology, PC

Name: ______Date: ______Please bring information to your appointment

Heme (Blood) Neuro

Anemia / Yes ( ) No ( )
Sickle Cell / Yes ( ) No ( )
Clotting Problem / yes ( ) No ( )
Blood Transfusion / Yes ( ) No ( )
Easy Bruising / Yes ( ) No ( )
Seizures / Yes ( ) No ( )
Stroke / Yes ( ) No ( )
Syncope/Dizziness / Yes ( ) No ( )
Weakness / Yes ( ) No ( )
Paralysis / Yes ( ) No ( )

Alcohol Use Yes ( ) No ( )

None, social, weekend or daily

______

Smoker Yes ( ) No ( ); If yes for how long and how much: ______