Comprehensive Cardiac Health History Form

Patient Information

• Full Name: _________________ Date of Birth: _________
• Sex: □ M □ F Gender Identity: _________
• Contact Number: _____________ Email: _____________

Primary Concerns

• Main reason for visit: _______________________________
• Duration of symptoms: _______________________________
• Severity (1-10): ___________________________________

Cardiovascular History

Please check all that apply:

Diagnosed Conditions

□ Hypertension □ Coronary Artery Disease □ Heart Attack (MI) - Date: _________ □ Heart Failure □ Arrhythmia □ Valve Disease □ Peripheral Vascular Disease

Current Symptoms

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

Previous Cardiac Procedures

□ Angioplasty/Stent - Date: _________ □ Bypass Surgery - Date: _________ □ Valve Surgery - Date: _________ □ Pacemaker/ICD - Date: _________

Risk Factors

• Smoking Status: □ Never □ Former □ Current
• Alcohol Use: □ Never □ Occasional □ Regular
• Exercise Frequency: _____ times per week
• Family History of Heart Disease: □ Yes □ No

Current Medications

Allergies

Other Medical Conditions

□ Diabetes □ High Cholesterol □ Kidney Disease □ Thyroid Disease □ Sleep Apnea □ Other: _______________________________________

Emergency Contact

Name: _________________ Relationship: _____________ Phone: _________________

Signature: ______________ Date: _________________