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Personal/Family History
After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
My provider is not in the list
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
Patient Information
*
Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
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December
Birth Day
1
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Birth Year
2021
2020
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1911
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1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Patient Medical History
* Required Information
Patient Medical History
Do you have any medical history?
Yes
No
Abnormal heart rhythm or EKG
Depression
Leg circulation problem
AIDS / HIV
Diabetes
Leg pain while walking
Anxiety
Dizziness
Liver disease
Arthritis
Emphysema
Lung disease or infection
Asthma
Glaucoma / cataracts
MRSA
Blood clots
Heart attack
Prostate disease
Bleeding disorder
Heart murmur
Psychiatric problems
Cancer (any type)
Heart valve disease
Rheumatic fever
Chest pain
Heart surgery
Shingles
Chronic cough
Hepatitis
Stomach ulcers
Congestive heart failure
High blood pressure
TIA / stroke
Convulsions or epilepsy
High cholesterol or triglycerides
Thyroid disease
Coronary artery disease
Kidney disease
Tuberculosis
Varicose veins
Patient Surgical History
Do you have any surgical history?
Yes
No
Ablation
Carotid surgery / stent
Orthopedic surgery
Aneurysm repair
Coronary angioplasty / stent
Ovary / ovaries removed
Appendectomy
Coronary bypass surgery
Peripheral angioplasty
Blood vessel surgery
Gallbladder surgery
PFO closure
Bowel surgery
Gastric bypass
Plastic surgery
Breast surgery
Heart valve surgery
Prostate surgery
Cataract surgery
Hernia repair
Thyroid surgery
Hysterectomy
Vascular stent
Defibrillator
Company name:
Medtronic
St. Jude
Boston Scientific
Biotronik
Unknown
Pacemaker
Company name:
Medtronic
St. Jude
Boston Scientific
Biotronik
Unknown
Family Medical History
Do you have any family medical history?
Yes
No
Family History Unknown
Coronary bypass surgery
Father
Mother
Sibling(s)
Diabetes
Father
Mother
Sibling(s)
Heart attack
Father
Mother
Sibling(s)
Heart disease
Father
Mother
Sibling(s)
High blood pressure
Father
Mother
Sibling(s)
Stent
Father
Mother
Sibling(s)
Stroke
Father
Mother
Sibling(s)
Sudden death
Father
Mother
Sibling(s)
Abnormal heart rhythm
Father
Mother
Sibling(s)
None of the above illnesses
Father
Mother
Sibling(s)
Mother, Grandmother, or Sister developed heart disease before the age of 65.
Father, Grandfather, or Brother developed heart disease before the age of 55.
Mother's status:
Alive
Deceased
Unknown
Died of:
Heart attack / sudden death
Other
Age at time of death:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
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84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Father's status:
Alive
Deceased
Unknown
Died of:
Heart attack / sudden death
Other
Age at time of death:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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81
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84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Patient Status
Please indicate
your
current living situation:
Living alone
Living with family / friends
Living in an assisted living facility
Living in a nursing home
Marital status:
Single
married
divorced
significant other
widowed
Employment status:
Employed
Unemployed
Retired
Disabled
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