Cardiac Surgery Patient Registration Form

Patient Information

• Full Name: _________________________ Date: __________
• Date of Birth: __________ Age: ____ Gender: ________
• SSN: _________________ Marital Status: ____________
• Address: ________________________________________
• Phone: (Home) ____________ (Cell) ________________
• Email: _________________________________________
• Emergency Contact: _____________ Phone: __________

Medical History

Cardiovascular History

• Previous Cardiac Procedures: □ Yes □ No
  • If yes, specify: _______________________________
• Previous Cardiac Catheterizations: □ Yes □ No
  • Date(s): ____________________________________
• History of: □ Angina □ MI □ CHF □ Arrhythmia □ Valve Disease

Current Medications

• Anticoagulants: □ Yes □ No
• Blood Pressure Medications: □ Yes □ No
• List all current medications: _____________________

Risk Factors

□ Hypertension □ Diabetes □ Smoking □ High Cholesterol □ Family History of Heart Disease

Insurance Information

• Primary Insurance: _____________________________
• Policy Number: ________________________________
• Secondary Insurance: ___________________________

Physician Information

• Primary Care Physician: ________________________
• Referring Cardiologist: _________________________

Consent

I verify that the above information is accurate and complete:

Signature: __________________ Date: ______________