Patient Forms
Patient Demographics
New Patient Medical Information
Authorization for Disclosure
(Release of Medical Records)
Revocation of Authorization
(Revoke of Medical Records)
New Patients should complete the Patient Demographics and New Patient Medical Information Forms prior to your scheduled appointment.
NEW PATIENT MEDICAL INFORMATION
Welcome to Southeastern Cardiovascular Consultants! In order for us to serve you better, please fill out the following information. Click the appropriate answer. Please answer all questions completely. This helps the doctor to evaluate you more thoroughly.
Your Name:
*
Last
*
First
Middle
Family Doctor’s Name :
*
DRUG ALLERGIES:
List any allergies that you have.
_____________________________________________________________________
1. CARDIOVASCULAR
8. IMMUNOLOGY
A Heart Attack
*
NO
YES
Frequent infections
*
NO
YES
High Blood Pressure
*
NO
YES
Organ transplant
*
NO
YES
Heart Catheterization/
Balloon Angioplasty or Stent
*
NO
YES
9. MUSCULOSKELETAL
Treadmill Exercise Test
*
NO
YES
Lung Disease
*
NO
YES
Heart Valve Problems
*
NO
YES
Fibromyalgia
*
NO
YES
Congestive Heart Failure
*
NO
YES
Arthritis
*
NO
YES
High Cholesterol/triglycerides
*
NO
YES
Other joint/muscle problems
*
NO
YES
Mitral Valve Prolapse (MVP)
*
NO
YES
Palpitations/Heart Racing
*
NO
YES
10. NEPHROLOGY
Are you on dialysis?
*
NO
YES
2. DERMATOLOGY
--If yes, what days do you go?
Psoriasis
*
NO
YES
Chronic Kidney Disease
*
NO
YES
Eczema
*
NO
YES
Rashes
*
NO
YES
11. NEUROLOGY
Have you ever had a stroke
*
NO
YES
3. EYES, EARS, NOSE, THROAT
Seizures
*
NO
YES
Problems with your eyes
*
NO
YES
Problems with your ears
*
NO
YES
1
2. ONCOLOGY
Problems with your nose
*
NO
YES
Cancer
*
NO
YES
Problems with your throat
*
NO
YES
Do you wear glasses/contacts
*
NO
YES
13. PULMONARY
Cataracts
*
NO
YES
Lung Disease
*
NO
YES
Glaucoma
*
NO
YES
Asthma
*
NO
YES
Emphysema
*
NO
YES
4. ENDOCRINE
High Sugar or Diabetes
*
NO
YES
14. PSYCHIATRIC
Thyroid Problems
*
NO
YES
Depression
*
NO
YES
Schizophrenia
*
NO
YES
5. GASTROINTESTINAL
Other mental illness
*
NO
YES
Stomach Problems
*
NO
YES
Problems with bowels
*
NO
YES
15. VASCULAR
Stomach Ulcers
*
NO
YES
Poor Circulation
*
NO
YES
Hiatal Hernia
*
NO
YES
Pain in legs with walking
*
NO
YES
Acid Reflux
*
NO
YES
Non healing ulcer on legs or feet
*
NO
YES
Indigestion
*
NO
YES
16. LYMPHATICS
6. GENITOURINARY
Swelling or edema
*
NO
YES
Problems with urination
*
NO
YES
Varicose Veins
*
NO
YES
Prostate problems
*
NO
YES
Female organ problems
*
NO
YES
7. HEMATOLOGY
Hepatitis
*
NO
YES
Sickle Cell
*
NO
YES
Anemia
*
NO
YES
Other blood problems
*
NO
YES
SURGICAL HISTORY
Have you ever had surgery?
*
NO
YES
If yes, describe.
What type of surgery?
Date performed?
Which facility?
/
/
/
/
/
/
HOSPITALIZATIONS
Have you ever been hospitalized other than for surgery?
*
NO
YES
If yes, describe.
Reason for Hospitalization
Date?
Which facility?
/
/
/
/
/
/
FAMILY HISTORY
Have either your Mother/Father/Brothers/Sisters had a Heart Attack, Stent or Stroke?
*
NO
YES
SOCIAL HISTORY
Have you ever smoked or used smokeless tobacco?
*
NO
YES
Quit:
mo.
/
year
How many packs per day?
How long have you smoked?
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