DATE __________

YOUR NAME ___________________________________

Date of Birth _______Age _____Gender Male___ Female ___ Height___ Weight ____

Race Caucasian___ Black ____ Hispanic _____ Other _________

What is your main medical problem?

____________________________________________________

What is your main symptom?

____________________________________________________

Check any illnesses or conditions which you have had:

Previous operations: (list the dates, hospitals, and names of surgeons)

________________________________________________________

________________________________________________________

________________________________________________________

Have you ever taken cortisone-type drugs? No___ Yes___

Have you taken oral contraceptives? No___ Yes___

Have you received a blood transfusion? No___ Yes___

Do you have any allergies to medicines or other substances? No___ Yes___     _____________________________

Check illnesses which have occurred in any of your blood relatives:

What medications are you currently using?

________________________________________________

________________________________________________

________________________________________________

Have you ever been diagnosed with a "heart attack" or Myocardial infarction?

No___ Yes___ When?_______________

History of Congestive Heart Failure? No ___ Yes ____

Diabetes? No____ Yes_______

If yes, what kind of treatment do you receive? Insulin___ Oral meds___ Diet___

Kidney failure? No ___ Yes ____ If yes, dialysis dependent? ______

Chronic Lung Disease? No ___ Yes ___ If yes, currently under treatment?_________

Hypertension? No ___ Yes ____ If yes, are you currently under treatment? ________

Cigarette smoker? No ___ Yes ___ Current? No ___ Yes ___

            How many packs per day? _______ For how many years? ____

            If you are a former smoker, when did you quit? ___________

Do you use alcoholic beverages? No ___ Yes ___

Type? __________Weekly amount? ________ For how long?________

Have you ever had: (Please check all that apply and give the date.)

Date

___Cardiac Catheterization ______________________

___PTCA/Angioplasty/Atherectomy/Stent____________

___Coronary Bypass Surgery ____________________

___Heart Valve surgery _________________________

___Abdominal aneurysm surgery _________________

___Carotid artery surgery _______________________

___Peripheral (leg) vascular surgery _______________

___Vein stripping _____________________________

___Congenital heart surgery _____________________

___Arrhythmia surgery/ablation ___________________

___Pacemaker _______________________________

___Implantable defibrillator ______________________