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The Heartbeat Clinic
Please note that our average time per patient in the first visit is 2-3 hours.
Date: ____/____/____
Patient: __________________________________ Date of birth: ___/___/___ Age: ____ Gender: M F
Occupation: _______________________________
Referring Doctor: ________________________
Please INDICATE all the reasons for your visit:
q Chest pain
q Shortness of Breath
q Palpitations
q Heart murmur
q Abnormal rhythm
q Dizziness/ Fainting
q Hypertension
q Heart failure/Swollen Legs
q Pre surgical evaluation
q Screening cardiac evaluation
q Establish new cardiologist.
H1. HAVE YOU HAD HEART DISEASE AND/OR PRIOR TESTING? YES NO
(if No, skip to next section)
Heart Murmur/Valve Prolapse NO YES
(If yes, what year? __________)
Rheumatic /Scarlet Fever NO YES
(If yes, what year? __________)
Heart Attack NO YES
(If yes, what year? __________. Location? __________________)
Heart Cath/ Angioplasty /Stent NO YES
(If yes, what year? __________. Location? __________________)
Bypass surgery NO YES
(If yes, what year? __________. Location? __________________)
Pacemaker NO YES
(If yes, what year? __________. Location? __________________)
Defibrillator (AICD) NO YES
(If yes, what year? __________. Location? __________________)
Heart Failure NO YES
(If yes, what year? __________)
Stress Test (treadmill) NO YES
(If yes, what year? __________. Location? __________________)
Echo / Ultrasound NO YES
(If yes, what year? __________. Location? __________________)
Nuclear Thallium PET Scan NO YES
(If yes, what year? __________. Location? __________________)
Carotid Ultrasound NO YES
(If yes, what year? __________. Location? __________________)
Holter (24hr tape) NO YES
(If yes, what year? __________. Location? __________________)
H2. WHICH OF THESE RISK FACTORS FOR HEART DISEASE DO YOU HAVE:
High Cholesterol NO YES
(If yes, what year? __________) TC____LDL____HDL____TG____
High Blood Pressure NO YES
(If yes, what year? __________), how was diagnosis initially established
Do you check your blood pressure at home?
What does your blood pressure at home
Diabetes NO YES
(If yes, what year? __________) Do you know your hemoglobin A1C
Female Menopause NO YES
(If yes, what year? __________) Hormones? YES NO
Current/Recent Smoker NO YES (Quit what year? __________)
Phen/Fen Weight Loss Medicine NO YES (If yes, what year? __________)
H3. BLOOD VESSEL DISEASES
Carotid Disease or Endarterectomy NO YES
(If yes, what year? __________)
Stroke or TIA (mini-stroke) NO YES
(If yes, what year? __________)
Aortic Aneurysm NO YES
(If yes, what year? __________)
Poor Leg Circulation NO YES
(If yes, what year? __________)
Leg Cramps While Walking NO YES
(If yes, what year? __________)
Venous Thrombosis (leg clots) NO YES
(If yes, what year? __________)
Pulmonary Embolism (lung clots) NO YES
(If yes, what year? __________)
H4. FAINTING SPELL/B;ACK OUT SPELLS/ DIZZINESS
Have you ever had a fainting or black out spell NO YES
If yes describe in your own words each spell or last three spells
FIRST FAINTING SPELL
SECOND FAINTING SPELL
THIRD FAINTING SPELL
Do any of above spells was accompanied by
Nausea/Vomiting Y N
Did they occur in standing or sitting posture Y N
Do you get lightheaded or dizzy when you stand up suddenly Y N
H5. PALPITATIONS
Do you have palpitations (awareness of heartbeat)
How would you classify your palpitations (circle one)
- Fast heartbeat
- Irregular heart beat
- Normal beat with skipped or extra beats
- Dont know
What do you think makes your palpitations worse (circle one)
- Stress
- Exercise
- Sleep
- After you eat
- Other
H6. PAST SURGICAL HISTORY (OPERATIONS) NO YES
Do not relist the cardiac operations already listed.
Example: Appendectomy YEAR: 1995 Location: MedicalCityDallas
1. _________________________________ YEAR _______ Location ___________________
2. _________________________________ YEAR _______ Location ___________________
3. _________________________________ YEAR _______ Location ___________________
H7. MEDICATIONS:
Please list all prescription and non-prescription medicines including vitamins and aspirin.
NAME DOSE/STRENGTH FREQUENCY
Example: Lasix 40 mg. 2 in am / 1 in pm
1. _________________________ ____________ __________/___________
2. _________________________ ____________ __________/___________
3. _________________________ ____________ __________/___________
4. _________________________ ____________ __________/___________
5. _________________________ ____________ __________/___________
6. _________________________ ____________ __________/___________
7. _________________________ ____________ __________/___________
8. _________________________ ____________ __________/___________
H8. DO YOU HAVE ANY ALLERGIES TO MEDICINES? YES NO (if No, skip to next section)
Please list all medications to which you have an allergy or adverse response and list the reaction (e.g. penicillin-arm rash)
Medication Reaction
1._______________________________ ________________________
2._______________________________ ________________________
3._______________________________ ________________________
4._______________________________ ________________________
H9. MEDICAL HISTORY:
1. Hepatitis/Jaundice NO YES (Year: __________)
2. Asthma NO YES (Year: __________)
3. Peptic Ulcer NO YES (Year: __________)
4. ____________________________________________________________
5. ____________________________________________________________
H10. SOCIAL HISTORY:
Marital Status: Married Separated Divorced Widowed Single
How many hours per week do you spend active? _________ hours
Do you drink alcohol q Never
I did, but have quit. (Year:____________)
Yes, ______ drinks per week.
H11. FAMILY HISTORY (Please fill out details of your biological relatives)
ILLNESS FATHER MOTHER BROTHER SISTER SON/S DAUGHTER/S
LIVING Y/N Y/N Y/N Y/N Y/N Y/N_________
AGE/S___________________________________________________________________
Heart attack, angina, coronary
bypass or angioplasty under age 55________________________________________________________________
Heart attack, angina, coronary
bypass or angioplasty age 55-65____________________________________________________________________
Stroke under age 65______________________________________________________________________________
Sudden Death_____________________________________________________________________________________
H12. AUTONOMIC NERVOUS SYSTEM QUESTIONNAIRE
(Autonomic nervous system plays a pivotal role in generation of many arrhythmias and related symptoms)
Use the scale below to complete the list regarding your symptoms and their frequency:
1: Never 2: < 1 time a month 3: 2-4 times a month
4: 5-7 times a month 5: daily
1 2 3 4 5 urinary incontinence or leaking
1 2 3 4 5 constipation
1 2 3 4 5 fatigue
1 2 3 4 5 nausea
1 2 3 4 5 headache
1 2 3 4 5 heartburn
1 2 3 4 5 clamminess of skin
1 2 3 4 5 tremulousness
1 2 3 4 5 impotence (for males)
1 2 3 4 5 sensation of rapid heartbeat
1 2 3 4 5 impaired memory
1 2 3 4 5 fainting
1 2 3 4 5 itching of the feet
1 2 3 4 5 chest discomfort
1 2 3 4 5 sensation of forceful, slow heartbeat
1 2 3 4 5 dizziness
1 2 3 4 5 feeling of weakness
1 2 3 4 5 frequent wakening during the night
1 2 3 4 5 shortness of breath
1 2 3 4 5 blurring or dimming of vision
1 2 3 4 5 difficulty emptying the bladder
1 2 3 4 5 excessive daytime sleepiness
1 2 3 4 5 loose, watery stools
1 2 3 4 5 anxiety
1 2 3 4 5 muscle aches
1 2 3 4 5 bloating after meals
1 2 3 4 5 itching of thehands
1 2 3 4 5 lightheadedness (faintness)
1 2 3 4 5 difficulty falling to sleep
1 2 3 4 5 difficulty with starting to urinate
1 2 3 4 5 sensation of head or room spinning
1 2 3 4 5 excessive sweating
1 2 3 4 5 confusion
1 2 3 4 5 neck or shoulder aching
1 2 3 4 5 joint aches
1 2 3 4 5 difficulty staying asleep
H13. REVIEW OF SYSTEMS:
Check any and all conditions you have.
GENERAL
Cancer (list site: _________________________)
ENDOCRINE
Low thyroid
EYES
Glaucoma
Cataracts
LUNG/BREATHING
Persistent Cough
Bronchitis
Emphysema
NEUROLOGICAL
Seizures/Epilepsy
ABDOMEN
Hiatus Hernia
Heartburn
KIDNEY/BLADDER
Dialysis
Kidney Stones
INFECTIONS
AIDS/HIV
BLOOD
Bleeding Problems
Leukemia
I have reviewed the above information with the patient on :
Date ________________________________
Signed ________________________________
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