Medical History Questionnaires Forms 3a, 3b

Med. History Questionnaires
Forms 3A

Date:(Required)

To evaluate your Health, your MEDICAL HISTORY is Necessary. It’s IMPORTANT that the questions are answered Truthfully and as complete as possible. Your information is confidential.

Sex(Required)

Age(Required)

DOB:(Required)

Providers:

Referring Provider(Required)

Primary Care Provider(Required)

Cardiologist:(Required)

Any Other Provider assisting in your care:(Required)

Past and Present Medical Problems:

High blood pressure:(Required)

Heart attack:(Required)

High cholesterol:(Required)

Stroke/TIA:(Required)

Heart Failure:(Required)

Atrial Fib/Arrhythmia:(Required)

PFO/Hole in Heart:(Required)

Cancer:(Required)

Covid:(Required)

Other Past Medical History not listed

Surgical History

Please list any surgeries that you have had in the past. Some of the more common ones are listed below Please circle and date if relevant

Amputation site:(Required)

Date of surgery

Aneurysm, repair/site(Required)

Date of surgery

Bladder/Prostate repair(Required)

Date of surgery

Carotid surgery(Required)

Date of surgery

Cataract(Required)

Date of surgery

Heart stent/bypass/(Required)

Date of surgery

Laparoscopy (abdominal scope)(Required)

Date of surgery

Lower extremity bypass/(Required)

Date of surgery

Orthopedic surgeries (Knee, shoulder/rotator cuff, hip replacement)(Required)

Date of surgery

Other Surgeries or procedures

Do you drink alcohol?(Required)

Beer/Wine/Liquor How many per week?

Do you ever use recreational Drugs?(Required)

How many packs per day do you or did you smoke?(Required)

When did you quit?

Family History

Please list which family member was affected:
Mother, Father, Brother, Sister, Grandmother (maternal/paternal), Grandfather (maternal/paternal)

Abdominal aortic aneurysm

Heart Disease

Bleeding Disorder

High Blood Pressure

Cancer

Type

Stroke

Diabetes

Enrollment Form - Page 3b
Medical History Questionnaire

Do you any known Allergies to Medications?

Date

Please list Medication and Reaction:

What is your current weight?(Required)

Med. History Questionnaires Forms 3A

Enrollment Form - Page 3b Medical History Questionnaire

Med. History Questionnaires
Forms 3A

Enrollment Form - Page 3b
Medical History Questionnaire