Cardiology New Patient Registration Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Social Security #: _______________
• Address: ________________________________________________
• Phone: (Home) _____________ (Cell) _____________ (Work) _____________
• Email: ________________________________________________
• Emergency Contact: _____________ Relationship: _____________ Phone: _____________

Insurance Information

• Primary Insurance: _________________ ID #: _________________
• Secondary Insurance: _________________ ID #: _________________

Cardiovascular History

Please check all that apply:

• □ High Blood Pressure
• □ Heart Attack
• □ Coronary Artery Disease
• □ Arrhythmia
• □ Heart Valve Disease
• □ Heart Failure
• □ Previous Cardiac Surgery

Current Symptoms

Please indicate if you are experiencing:

• □ Chest Pain/Pressure
• □ Shortness of Breath
• □ Palpitations
• □ Dizziness/Fainting
• □ Swelling in Legs/Ankles
• □ Exercise Intolerance

Current Medications

Family History

Please indicate if any blood relatives have had:

• □ Heart Disease
• □ High Blood Pressure
• □ Diabetes
• □ Stroke

Lifestyle Factors

• Smoking Status: □ Never □ Former □ Current
• Alcohol Use: □ None □ Occasional □ Regular
• Exercise Frequency: □ None □ 1-2x/week □ 3+x/week

Authorization

I certify that the above information is accurate and complete to the best of my knowledge.

Signature: _________________ Date: _________________