Referring Physician_______________________________
Medical Record #________________________________
Patient Information
Name__________________________________________________________________________________________________________
Address___________________________________________ Apt. #__________ Home Phone__________________________________
City, State, Zip______________________________________________ Work Phone__________________________________________
Birthdate_____________ Sex_____ Height__________ Weight__________ Marital Status: S M W D Sep.
SS#____________________________________ Employment Status: Full Part Retired Self None
Employer Name__________________________________________ Occupation____________________________________________
Employer Address________________________________________ City, State, Zip__________________________________________
Emergency Contact______________________________________________________________________________________________
Relationship____________________________________________
Phone Number___________________________________________
Insurance Information
Please Provide Insurance Card(s) to
Enable Us to Make Copies
Primary Insurance Co.____________________________________________________________________________________________
Subscriber's Name______________________________________________ Employer________________________________________
Subscriber's Social Security No.____________________________________
Date of Birth_____________________________________
Secondary Insurance Co._________________________________________________________________________________________
Subscriber's Name______________________________________________ Employer________________________________________
Subscriber's Social Security No.____________________________________
Date of Birth_____________________________________
I consent to office care encompassing routine technical procedures and medical treatments performed by my attending physician, his/her assistant or designees, as may be necessary in his/her best medical judgement.
I acknowledge full responsibility for payment of services and agree to pay them. I hereby authorize of any information including the diagnosis and the records of any treatments or examinations rendered, to my insurance company(ies). This release is solely for the purpose of facilitating the payment directly to the physician, the insurance benefits payable according to my plan and/or policy.
Signature of Patient (or guardian if minor)
_______________________________________________________ Date__________________
Isaac Thomas, MD
Cardiologist
1 S. Greenleaf Ave.
Suite I
Gurnee, IL 60031
(847) 336-1600
Name___________________________________ Age_____________ Sex_______________ Date______________
Address____________________________________________________ Tel. No. (H)___________________________
City/State________________________________ ZIP______________ Tel. No. (W)___________________________
Date Of Birth____________________________
CARDIOVASCULAR QUESTIONS
1. Have you ever had pressure pain or discomfort in the chest or arm? Yes____________ No____________
2. Is the pain or discomfort
located,
a.
in the back between shoulder blades
Yes____________ No____________
b.
beneath the breast
Yes____________ No____________
c.
in the left arm
Yes____________ No____________
d.
in the right arm
Yes____________ No____________
e.
in the middle
Yes____________ No____________
f.
some other place in the chest
Yes____________ No____________
3. Is the pain produced
by,
a.
exertion (climbing, sexual intercourse, etc.)
Yes____________ No____________
b.
exposure to the cold
Yes____________ No____________
c.
being upset
Yes____________ No____________
4. Does the pain wake you up at night? Yes____________ No____________
5. Does the pain get worse with deep breath? Yes____________ No____________
6. Does it get worse
by moving the arm or it does
Yes____________ No____________
occur
with special movements?
7. How long does it last?__________________________________________________________________________________________
8. How do you get relief?
a.
with rest
Yes____________ No____________
b.
with meals and milk
Yes____________ No____________
c.
with antacid
Yes____________ No____________
9. How long have you had recurrent chest discomfort?_____________________________________________________________________________________________________
10. How often do you have chest discomfort?__________________________________________________________________________
11. Is the pain associated
with,
a.
shortness of breath
Yes____________ No____________
b.
dizziness
Yes____________ No____________
c.
nausea and vomiting
Yes____________ No____________
d.
palpitation
Yes____________ No____________
12. Have you ever had
shortness of breath or cough in the
middle of the night that wakes you up?
Yes____________ No____________
13. Do you elevate your
head with a pillow in order
to breathe at night?
Yes____________ No____________
14. Have you ever had swelling of your ankles? Yes____________ No____________
15. Do you get shortness
of breath when climbing
stairs or walking?
Yes____________ No____________
16. Do you cough up phlegm? Yes____________ No____________
17. Have you ever coughed up blood? Yes____________ No____________
18. Have you ever had dizziness or syncope? Yes____________ No____________
19. Do you wheeze? Yes____________ No____________
20. Have you noticed
palpitation (fluttering of the heart)
or skipped beats?
Yes____________ No____________
21. Do you get pain in your calves when you walk? Yes____________ No____________
22. Have you ever had
sudden blurred vision in one
or both eyes?
Yes____________ No____________
23. Have you ever been told that your blood pressure is high? Yes____________ No____________
24. Have you ever been told that you have diabetes? Yes____________ No____________
25. Have you ever been
told that you have high cholesterol,
or that your high density cholesterol is low?
Yes____________ No____________
26. Do you drink alcohol?
Yes____________ No____________
If yes, how much?
27. Do you smoke cigarettes?
Yes____________ No____________
If yes, how many?____________ How many years?____________
28. Have any of your
blood relatives had,
a. heart attack
Yes____________ No____________
b. high blood pressure
Yes____________ No____________
c. high cholesterol
Yes____________ No____________
d. diabetes
Yes____________ No____________
e. sudden death
Yes____________ No____________
f. bleeding problem
Yes____________ No____________
29. Do you feel you are under pressure most of the time? Yes____________ No____________
30. Do others feel you are over critical of yourself or your work? Yes____________ No____________
31. Have you been losing weight non voluntarily? Yes____________ No____________
32. Are you allergic
to any drug or any substance?
If yes, please list:
1.____________________________________________________________
2.____________________________________________________________
3.____________________________________________________________
33. Are you currently
taking any medications?
Yes____________ No____________
If yes, please list all medications with the dosage:
1.________________________________________________ 4.________________________________________________
2.________________________________________________ 5.________________________________________________
3.________________________________________________ 6.________________________________________________
34. Have you ever been
hospitalized?
Yes____________ No____________
If yes, please list the reasons:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
35. Do you have any other
complaints?
Yes____________ No____________
If yes, please list:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
36. How were you referred to us?___________________________________________________________________________________
__________________________________________________________________________________________________________
Referred by Dr.____________________________________________________________________________________
Yellow Pages_____________________________________________________________________________________
Other___________________________________________________________________________________________