Arkansas Cardiology New Patient Questionnaire

First Name:         Middle Initial:         Last Name:


Address Line 1:     Apt/Suite/Unit:

Address Line 2:

City:     State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming         Zip:

E-Mail:

Home Phone:       Work Phone:       Mobile Phone:

Age:     Gender: Male Female         Social Security Number: 

Date of Birth:   Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

AR Cardiology Physician:	First Available Physician Dr. Dwight Chrisman Dr. Gary Collins Dr. Scott Davis Dr. Stephen Greer Dr. Douglas Holloway Dr. David G. Jones Dr. Randy Minton Dr. Blake Norris Dr. Alex Orsini Dr. B.K. Singh Dr. Thomas Conley Dr. Robert Lambert Dr. Jeffery Neuhauser Dr. Jay Geoghagan	Referring Physician:
Primary Pharmacy:		Pharmacy Phone Number:

Please list all the doctors you see:

Doctor's Name:	Type of Doctor:	Reason for Seeing:

Briefly describe the reason for your visit:

Allergies:

Have you ever had a reaction to Iodine?  Yes No
Please list any other medication allergies:

Allergy to:	Reaction:

Medications:

Medication Name:	Dosage:	Frequency:	Prescribing MD:

Cardiac History:

Please check if you have or have had any of the following problems:

Heart Attack:	Congestive Heart Failure:	Chest Pain:	High Blood Pressure:
Shortness of Breath:	High Cholesterol:	Palpitations/Racing Heart:	Abnormal EKG:
Dizziness:	Rheumatic Fever:	Fainting/Loss of Consciousness:	Blood Cots in the legs:
Leg Swelling/Leg Pain:	Pulmonary Embolism:

Previous Cardiac Procedures:

Procedure	Date	Location	Physician
Heart Catheterization
Stent Placement
Coronary Artery Bypass Grafting
Valve Replacement
ElectroPhysiology Study
Pacemaker/AICD Implant
Stress Test
Echocardiogram
Holter Monitor
CT/MRI

Cardiac Risk Factors:

Do you currently smoke?     No Yes     How many packs per day and for how long?    
        Have you previously smoked?     No Yes     When did you quit?
        How many packs per day and for how long?    
Do you have high blood pressure? No Yes When were you diagnosed?    
Do you have high cholesterol? No Yes When were you diagnosed?    
        Date of last Lab Check:
Do you have diabetes? No Yes Do you have Type I or Type II diabetes? Type I Type II When were you diagnosed?    
        Date of last Hemoglobin A1C:
Do you have Peripheral Vascular Disease (PVD)? No Yes

Past Medical History:

Please list any medical conditions that you have:

Past Surgical History:

Please provide the date for any that apply.

Tonsillectomy		Gallbladder		Knees
Appendectomy		Prostate		Hips
Hysterectomy		Cataracts		Hernia

Other Surgeries:

Social History:

Marital Status: Single Married Divorced Widowed     Spouse's Occupation:
Do you have children? No Yes     Boys:     Girls:
What is your ethnicity? African American Asian Caucasian Hispanic Native American Pacific Islander     Other:
Are you on a special diet? No Yes If yes, what kind?:
Do you drink caffeine? No Yes If yes, what kind?:
Do you exercise regularly? No Yes If yes, what type of exercise and how often?:
Do you Drink Alcohol? No Yes, rarely Yes, occasionally Yes, socially Yes, frequently Yes, daily
Do you have a history drug abuse? No Yes If yes, please specify:
Place of birth:
Religion:
Have you traveled recently? No Yes If yes, where:

Education:

Occupation:

Family History:

Are you adopted? No Yes

Relationship	Condition	Age	Deceased

Review of Systems:

General:

Change in weight?	Gain Loss No Change
Change in appetite?	No Yes
Fatigue/Weakness?	No Yes
Decrease in Exercise Tolerance?	No Yes

Cardiac:

Chest-pain, tightness or pressure?	No Yes
Palpitations/Racing Heart?	No Yes
Irregular heart beats?	No Yes
Shortness of breath?	No Yes
Dizziness?	No Yes
Fainting?	No Yes
Swelling of ankles or feet?	No Yes
Leg-pain when walking?	No Yes

Respiratory:

Chronic cough?	No Yes
Pneumonia?	No Yes
Asthma?	No Yes
Tuberculosis?	No Yes
Do you snore?	No Yes
Do you have sleep apnea?	No Yes
If yes, do you wear a CPAP?	No Yes

Eyes:

Glasses/Contacts?	No Yes
BLurred Vision?	No Yes
Double Vision?	No Yes
Cataracts?	No Yes
Glaucoma?	No Yes

Ear, Nose, Throat:

Hearing Loss?	No Yes
Ringing in Ears (Tinnitus)?	No Yes
Dentures/Braces?	No Yes

Gastrointestinal:

Nausea/Vomiting?	No Yes
Diarrhea?	No Yes
Abdominal Pain?	No Yes
Bleeding Ulcer?	No Yes
GERD (Reflux)?	No Yes
Diverticulitis/Colitis?	No Yes

Endocrine:

Hyperthyroidism (overactive)?	No Yes
Hypothyroidism (underactive)?	No Yes
Insulin-dependent diabetes?	No Yes
Non-Insulin dependent diabetes?	No Yes

Musculoskeletal:

Chronic back pain?	No Yes
Osteoarthritis?	No Yes
Rheumatoid arthritis?	No Yes
DJD (degenerative joint disease)?	No Yes
Gout?	No Yes

Neurological:

Blurred or loss of vision?	No Yes
Weakness/tingling in extremities?	No Yes
Stroke (CVA)?	No Yes
Migraine Headaches?	No Yes
Tremors?	No Yes
Parkinson's Disease?	No Yes
Seizure Disorder?	No Yes

Genitourinary:

History of bladder cancer/dysfunction?	No Yes
History of prostate cancer/dysfunction?	No Yes
Kidney Failure?	No Yes
Kidney stones?	No Yes

Hematologic/Blood:

Anemia?	No Yes
Leukemia?	No Yes
Have you received blood transfusions?	No Yes

Psychiatric:

Depression?	No Yes
Anxiety?	No Yes
Trouble Sleeping	No Yes

Other:

Have you ever had chemotherapy or radiation treatments?	No Yes
If yes, when was your last treatment?
Please provide the most recent dates that apply to you:
Last Mammogram:
Colonoscopy:
Flu Vaccine:
Pneumonia Vaccine: