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Date:________________________________

Patient Name:________________________

Referred by:_________________________

Mailing Address:_____________________

Telephone:___________________________

Your Email Address:__________________

Date of Birth:_______________________

Gender: Male Female

Primary Care Physician Name, Address and Phone:__________________

Emergency Contact Name:______________

Relationship:________________________

Phone:_______________________________

Your Height:_________________________

Your Weight:_________________________

What seems to be the problem?
What is the reason for consultation?

Do you have high blood pressure or are you taking a blood pressure medication?
    Yes
    No
    I Don't Know
What are your smoking habits?
    I currently smoke
    I have never smoked
    I used to smoke, but have quit
Do you have high cholesterol or are taking a cholesterol lowering medication?
    Yes
    No
    I Don't Know
Do you have diabetes?
    Yes, I was diagnosed as an adult (over 21 years old)
    Yes, I was diagnosed prior to age 21
    No
Have you ever had a heart attack or stroke?
    Yes
    No
Have you ever had any heart procedures, such as stents, balloon angioplasty or bypass surgery?
    Yes
    No
Has anyone in your immediate family (father, mother, sibling) had a heart attack?
    Yes
    No
How would you describe your stress level?
    I have minimal or low stress
    I have a moderate level of stress
    I have a high level of stress
How would you describe your level of physical activity?
    Very Active
    Moderately Active (about 30 minutes of activity 3 days per week)
    Not Active
I would best describe my alcohol usage as the following
    Light Drinker (less than 1 drink per week)
    Moderate Drinker (1-2 drinks per day)
    Heavy Drinker (3 or more drinks per day)
    I don't drink
Do you follow a low fat, low carb or vegetarian diet?
    Yes
    No
Do you eat red meat, packaged foods, fast food, or fried food 3 or more times per week?
    Yes
    No
Do you eat fish 3 or more times per week or take a daily fish oil supplement?
    Yes
    No
Do you currently have any periodontal diseases such as gingivitis?
    Yes
    No
Do you take aspirin daily?
    Yes
    No

These are basic questions.
There are many more.


When should you call Emergency Medical Services?

Do you have any of these symptoms, signs, or problems?

New chest pain or discomfort that is severe, unexpected, and occurs with shortness of breath, sweating, nausea, or weakness.

Palpitations with a resting adult heart rate of more than 100 per minute.

Palpitations with a resting adult heart rate of more than 100 per minute five minutes after brisk walk or exercise.

Shortness of breath not relieved by rest.

Fainting spell with loss of consciousness.

New irregular heartbeat.

Chest pain or discomfort during activity that is relieved with rest.

Difficulty breathing during regular activities or at rest.

Decreased urination.

Restlessness, confusion.

Constant dizziness or lightheadedness.

Nausea and vomiting.