Patient Medical History

Patient First Name

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Patient Last Name

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MRN:

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Date of Birth:

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Primary Care Provider

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Cardiologist / Specialist:

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Diagnosis:

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Surgical Procedure:

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Surgeon:

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Height:

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Weight:

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BMI:

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Do you have or are you being treated for high blood pressure?

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If yes, how many years?

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Do you have chest pain with walking/normal activity? With exercise?

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Have you ever had a coronary bypass or angioplasty?

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Have you ever had a heart attack?

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If yes, how many

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When did you have a heart attack?

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Do you have a heart stent?

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If yes, how many?

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When did you have a heart stent?

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Do you have a weak or failing heart (congestive heart failure, CHF)?

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Do you have an irregular heartbeat or heart rhythm?

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Do you have a heart murmur or mitral valve prolapse?

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Have you ever had a heart valve replacement or repair?

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Do you have a pacemaker or defibrillator?

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Have you ever been told that you have a widening of your aorta or that you have an aortic aneurysm?

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Have you ever been told you have peripheral vascular disease?

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Have you ever had a stress test?

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If yes, where?

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If you have had a stress test, when did you have it?

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Have you ever had a cardiac echo test?

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If yes, where?

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If you have had a cardiac echo test, when did you have it?

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Have you ever had a heart catheterization?

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If yes, where?

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If you have had a heart catheterization, when did you have it?

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Do you take daily medication for asthma?

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Do you have a history of chronic bronchitis or emphysema (COPD)?

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Do you smoke?

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If yes, how many packs a day?

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If you do smoke, how many years have you been a smoker?

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Have you had any recent colds, fever or flu symptoms?

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Do you have difficulty breathing (do you wheeze)?

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Do you use supplemental oxygen?

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Do you have a history of sleep apnea? CPAP?

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Have you ever been witnessed to stop breathing while asleep?

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Do you have diabetes?

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If yes, for how many years?

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If you do have diabetes, what are your complications?

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Do you have kidney problems (other than kidney stones)?

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Do you have liver problems?

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Have you ever had Hepatitis A / B / C / D?

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Do you drink alcohol every day?

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If yes, how many drinks do you have a day?

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Do you use recreational drugs?

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If yes, specify which drugs:

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Do you have a history of anemia?

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Do you take any blood thinners (e.g. Coumadin)?

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Do you take Aspirin or Ibuprofen regularly?

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Do you have a history with sickle cell disease or trait?

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Do you have a history of cancer?

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Are you on Chemo Therapy

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Do you have seizures or take anti-seizure medications?

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Have you ever had a stroke (CVA), mini stroke (TIA) or brain attack?

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If yes, when?

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Do you have neuromuscular disease (including Parkinson's, ALS, etc.)?

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Do you have a brain tumor, brain aneurysm or other vascular lesion of the brain?

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Have you been told that it is difficult to place a breathing tube in your airway (intubate)?

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Do you or a family member have a history of high fever after anesthesia (malignant hyperthermia)?

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Do you have a history of severe nausea and vomiting after anesthesia?

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Do you have a history of severe reaction to anesthesia?

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Do you suffer from chronic pain?

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Is there a possibility you could be pregnant?

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If yes, when was your last menstrual period?

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Do you have autoimmune disease (such as Rheumatoid Arthritis, Sarcoidosis, or Lupus)?

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Do you have any other medical problems that we have not asked you about? If yes, please specify below.

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Please list the medications you currently take and the dose:

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