CVG - Gwinnett Heart













CVG doctors and Staff only

Registration

* indicates required fields. For your privacy, this page is secure.

*NAME:

*DATE OF BIRTH:

AGE:

I. Describe in your own words why you need to see a cardiologist.

II. Past Medical Illness: Have you ever had any of the following medical problems? If so, when?

Heart attack	Yes No
Stroke	Yes No
High Blood Pressure	Yes No
Cancer	Yes No
Asthma	Yes No
Diabetes	Yes No
Ulcers	Yes No
Vascular disease	Yes No
Rheumatic Fever	Yes No
Mitral valve prolapse	Yes No
Hepatitis	Yes No
Thyroid disease	Yes No
Kidney disease	Yes No
Endocarditis	Yes No
Emphysema	Yes No
Hiatal hernia	Yes No
Gallbladder disease	Yes No
Elevated cholesterol	Yes No

III. Past Surgical History: Please list any previous surgical procedures along with the date of the procedure.

IV. Have you ever had a cardiac catheterization, angioplasty, stress test, or nuclear isotope stress test? If so, when and where?

V. Please list all medications that you are presently taking along with the dosage (strength) and frequency (number of times per day).

VI. Please list all over-the-counter medications that you are presently taking (i.e., decongestants, diet pills, NoDoz, etc.).

VII. Have you ever used or taken Redux or Phen-Fen?

VIII. Are you allergic to any medications? If so, please list them.

IX. Do you smoke presently or have you smoked in the past? If so, please list number of years smoked and number of packs per day.

X. How much alcohol do you consume? Please be specific.

XI. How much caffeine do you consume? Please be specific.

XII. Have you ever used recreational drugs?

XIII. Do you have a family history of heart disease? If so, please list specific relationships, types of heart disease, and ages at which they acquired heart disease.

XIV. What is your occupation?

XV. System Review (please circle Yes or No):

Do you have pain or burning in the muscles of your legs?	Yes No
Have you had recent fevers or shaking chills?	Yes No
Have you had recent unexplained weight loss or weight gain?	Yes No
Have you ever passed out?	Yes No
Do you have problems with migraines or frequent headaches?	Yes No
Do you have temporary blindness or double visions?	Yes No
Do you have difficulty swallowing?	Yes No
Do you have nosebleeds?	Yes No
Do you have vertigo (severe dizziness)?	Yes No
Do you have chronic coughing or wheezing?	Yes No
Do you have shortness of breath with exertion?	Yes No
Have you ever coughed up blood?	Yes No
Have you ever had chest pain or chest tightness?	Yes No
Do your feet swell?	Yes No
Do you wake up with shortness of breath?	Yes No
Do you prop up on pillows to sleep?	Yes No
Do you have palpitations, racing, or skipping of your heartbeat?	Yes No
Do you have problems with constipation or diarrhea?	Yes No
Do you pass blood in your bowel movements?	Yes No
Have you passed black, tarry bowel movements?	Yes No
Do you have problems passing your urine?	Yes No
Do you have pain or burning with urination?	Yes No
Do you get out of bed at night to urinate?	Yes No
Have you ever passed blood in your urine?	Yes No
Do you have any forms of arthritis?	Yes No