Patient Forms

This patient form is only for use by registered patients of Cardiovascular Specialists. Please see our Legal Disclaimer. To learn more about Cardiovascular Specialists, or to set up an appointment, please contact us at (402)-398-5880.

Click here for a printable version of this form.

Basic Information

Name:
Appointment Date:
Date of Birth:
Sex:
Primary Physician:
Chief Complaint:

Risk Factors

Smoke: Yes No Former Smoker
If yes or former smoker: Years: Packs/day
  Year quit:
High Blood Pressure: Yes No    How Long?
High Cholesterol: Yes No On Cholesterol Drug
Diabetes: Yes No    How Long?
Family history of early heart disease (60 years or less):
Yes No

Medical History

Heart attack: Yes No     When?
Angioplasty / Stent: Yes No     When?
Coronary Artery Bypass Grafting: Yes No     When?
Peripheral Vascular Disease: Yes No     When?
Sleep Apnea: Yes No
Congestive Heart Failure: Yes No
Stroke / Mini Stroke: Yes No     When?
Lung problems: Yes No
Blood clots in legs or lungs: Yes No
Hypothyroid/Hyperthyroid: Yes No
Stomach problems
(ulcer, hernia, reflux):
Yes No
Liver Problems: Yes No
Rheumatic Fever: Yes No
Kidney, bladder, prostate problems: Yes No
Carotid artery blockage: Yes No
Eye problems
(cataract, glaucoma, etc):
Yes No
Arthritis: Yes No
Psychiatric problems
(anxiety, depression, etc.):
Yes No
Other: Yes No
Surgeries (list procedures and year):

Family History

Have any of your relatives had any chronic illnesses(cancer, heart disease, diabetes, etc)?

Biological Father: Yes No    Alive Deceased
Biological Mother: Yes No    Alive Deceased
Maternal Grandmother: Yes No    Alive Deceased
Maternal Grandfather: Yes No    Alive Deceased
Paternal Grandmother: Yes No    Alive Deceased
Paternal Grandfather: Yes No    Alive Deceased
Siblings: Yes No    Alive Deceased
Aunt(s): Yes No    Alive Deceased
Uncle(s): Yes No    Alive Deceased


Social History

Caffeine intake (cups per day of caffeinated coffee, tea, cola):
Alcohol: Never Rarely
  Socially Daily
Drinks per day/week:
Number of years drinking:
Diet: Balanced Low fat / low cholesterol
  Low salt No special diet
  Other:
Regular exercise: Yes No
Type of exercise:
Times per week:
Marital status: Married Single
  Widow Divorced
Children: Yes - how many: No
Occupation:
Education: High School College
  Postgraduate

Allergies

List medication and reaction; include food and seasonal allergies.




Review of Systems

Check the items that you presently have.

General:
Recent weight loss
Recent weight gain
Fatigue
Fever
Chills
Night Sweats

Eye:
Blurred vision
Double vision
Blind
Glasses/Contacts

Ear / Nose / Throat:
Hearing loss
Ringing in ears
Nosebleeds
Hearing Aids
Runny Nose
Sore Throat

Respiratory:
Shortness of breath
Cough
Cough up blood
Snore/Stop Breathing during Sleep
Hard to breathe lying flat

Gastrointestinal:
Blood in stool
Black, tarry stools
Heartburn
Nausea/Vomiting
Diarrhea
Constipation
Abdominal pain

Kidney / Bladder System:
Blood in urine
Frequent urination at night
Burning with Urination
Difficulty Urinating

Musculoskeletal:
Arthritic Pain
Calf Pain with Walking
Low Back Pain
Leg Pain with Walking
Leg Pain That Wakes You From Sleep

Skin:
Rash or skin change

Neurologic:
Transient blurred vision
Weakness on one side
Slurred speech
Numbness
Dizziness
Fainting spells
Seizures
Tingling

Hematology:
Bruise easily
Bleeding problems


Cancer History

Have you ever been diagnosed with cancer in the past? If you have, please list details of the cancer treatment you received. (Include type of cancer, date diagnosed, by whom, and treatment).

Please include details of treatment if known. (Chemotherapy, Surgery, Radiation, Hormone, etc.)

Current Diagnosis

Type of Cancer:

Date:

Recent Problems

Have you had any problems of the following?

Recent Hospitalization

When:
Hospital:

Recent lab tests

When:
Lab:

Cardiac tests

Type:
When:
Where:

Peripheral Vascular Ultrasound Tests

Type:
When:
Where:

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