Cardiac Surgery Pre-Operative Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: _________________
• Medical Record #: __________ Date: _________________

Cardiovascular History

Primary Cardiac Condition (check all that apply)

• Coronary Artery Disease
• Valvular Heart Disease
• Aortic Aneurysm/Dissection
• Congenital Heart Disease
• Other: _________________

Previous Cardiac Procedures

• Prior Cardiac Surgery: Yes [ ] No [ ] Date: _________________
• Prior Coronary Interventions: Yes [ ] No [ ] Date: _________________
• Pacemaker/ICD: Yes [ ] No [ ] Date: _________________

Cardiovascular Risk Factors

• Hypertension
• Diabetes
• Hyperlipidemia
• Smoking History
• Family History of Heart Disease

Other Medical History

Respiratory

• COPD/Emphysema
• Asthma
• Sleep Apnea

Other Systems

• Renal Disease
• Liver Disease
• Bleeding Disorders
• Stroke/TIA

Current Medications

Allergies

Medication/Substance | Reaction |

Physical Examination

• Height: _____ Weight: _____ BMI: _____
• BP: _____ HR: _____ O2 Sat: _____

Authorization

I confirm that the information provided is accurate to the best of my knowledge.

Patient Signature: _________________ Date: _________________ Physician Signature: _________________ Date: _________________