HeartSmart Patient Packet

HeartSmart Patient Packet
We are so excited you are getting a HeartSmart exam! Please be advised that this intake form is comprehensive and takes 15-30 minutes. The progress bar is visible at the top of your page.

We would recommend completing it in one sitting if you are able to ensure that it gets submitted. However, there is an option to save your progress and continue later. Simply click "save" at the bottom of the page, and you will receive an email with a link to complete your form.

You DON'T need to create an account to use the "save" feature. Simply click "Skip Create an Account."

See instructions below. 👇
Got it!
IF YOU HAVE PROBLEMS filling out this online form, please use the printable form on our website! You can find it by clicking here.

CANCELLATION POLICY
Please inform us at least 72 hours prior to your appointment if you need to cancel or reschedule your appointment. This allows us to offer this appointment slot to other patients. Please note that we reserve two hours of time with our staff for your appointment, so late cancellations significantly affect us. Patients who cancel or reschedule less than 72 hours prior to their appointment will be charged a $200 cancellation fee. Please contact our office if you have any questions.

For this reason, please make sure your scheduled exam is on your calendar.
I understand*

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APPOINTMENT PREPARATION INSTRUCTIONS
1) Fasting

Please refrain from eating for eight (8) hours prior to your visit.
- Please DO drink water, but avoid all other beverages.
- You may take medications with water.
- Please refrain from consuming alcohol for 24 hours prior to your visit.
- You are welcome to bring a snack to eat after the fasting portions of your tests have been completed.
2) Clothing

Because your visit includes an EKG, you should wear appropriate clothing.

3) Medical History

Some of the questions regarding family history are critical for formulating an accurate “risk score” and providing a comprehensive medical evaluation, and may require inquiry or research. A detailed family medical history will help our medical providers interpret the history of disease in your family and identify patterns that may be relevant to your own health. This form is needed to assess your risk of certain diseases, determine which diagnostic tests to order as well as type and frequency of screening tests, identify a condition that might not otherwise be considered, and assess your risk of passing a condition on to your children.

Please fill it out to the best of your ability, and if you have questions about portions or were not sure of the best answer, we will review this form with you during your visit.
I understand*

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1) Demographics
Date

MonthDayYear
Date
Email (kept confidential)*
example@example.com
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Biological Gender*

MaleFemale
Can we send you email communication?*

SureNo thanks

4) Weight / Dieting History
Do you want to change your eating habits?*

NoYes
Why?*
Are members of your family overweight?*

NoYes
Please explain*
What was your weight at age 20? (in pounds)*

5) Past Surgeries, Procedures & Diagnostic Tests

List past testing, hospital visits and surgeries (for example, stent, cath procedure, heart surgeries, exercise tests, heart scan, MRI, CT scan, etc.) PLEASE DO NOT WRITE: "My physician has copies of all tests"
Surgery Type / Diagnostic Test
Is this a current problem?*

CurrentIn the Past
Date of test/surgery*

MonthDayYear
Date
Physician or Hospital where procedure took place:*
Additional Surgery Type / Diagnostic Test
Is this a current problem?*

CurrentIn the Past
Date of test/surgery*

MonthDayYear
Date
Physician or Hospital where procedure took place:*
Additional Surgery Type / Diagnostic Test
Is this a current problem?*

CurrentIn the Past
Date of test/surgery*

MonthDayYear
Date
Physician or Hospital where procedure took place:*
Additional Surgery Type / Diagnostic Test
Is this a current problem?*

CurrentIn the Past
Date of test/surgery*

MonthDayYear
Date
Physician or Hospital where procedure took place:*
Additional testing or comments:

6) Allergies

List allergies and type of reaction. Include medications, food, and seasonal/environmental allergies (animals, latex, smoke, etc.)
Do you suffer from allergies?*

No known allergies or never have been diagnosed with any allergiesYes
List allergies and type of reaction. Include medications, food, and seasonal/environmental allergies (animals, latex, smoke, etc.)
Allergy 1*
Allergy 1 Reaction*
Allergy 2
Allergy 2 Reaction*
Allergy 3
Allergy 3 Reaction*
Allergy 4
Allergy 4 Reaction*
Allergy 5
Allergy 5 Reaction*
Allergy 6
Allergy 6 Reaction*
Allergy 7
Allergy 7 Reaction*
Allergy 8
Allergy 8 Reaction*
Allergy 9
Allergy 9 Reaction*
Allergy 10
Allergy 10 Reaction*

7) Medications
List medication type and amount of medications you use on a regular basis.

Include:
- prescription,
- over-the-counter,
- birth control,
- hormones,
- vitamins,
- herbs,
- nutritional supplements
- and recreational drugs.
This form allows for 14 entries. If you take more than that on a regular basis, please bring a list to your appointment.
Medication #1
(Example: Aspirin)
Dosage/Frequency
(Example: 81mg per day)
Reason for taking this medication
Started (Format Month/Year)
Medication #2
Dosage/Frequency (Example: 81mg per day)
Reason for taking this medication
Started (Format Month/Year)
Medication #3
Dosage/Frequency (Example: 81mg per day)
Reason for taking this medication
Started (Format Month/Year)
Medication #4
Dosage/Frequency (Example: 81mg per day)
Reason for taking this medication
Started (Format Month/Year)
Medication #5
Dosage/Frequency (Example: 81mg per day)
Reason for taking this medication
Started (Format Month/Year)
Medication #6
Dosage/Frequency (Example: 81mg per day)
Reason for taking this medication
Started (Format Month/Year)
Medication #7
Dosage/Frequency (Example: 81mg per day)
Reason for taking this medication
Started (Format Month/Year)
Medication #8
Dosage/Frequency (Example: 81mg per day)
Reason for taking this medication
Started (Format Month/Year)
Medication #9
Dosage/Frequency
Reason for taking this medication
Started (Format Month/Year)
Medication #10
Dosage/Frequency
Reason for taking this medication
Started (Format Month/Year)
Medication #11
Dosage/Frequency
Reason for taking this medication
Started (Format Month/Year)
Medication #12
Dosage/Frequency
Reason for taking this medication
Started (Format Month/Year)
Medication #13
Dosage/Frequency
Reason for taking this medication
Started (Format Month/Year)
Medication #14
Dosage/Frequency
Reason for taking this medication
Started (Format Month/Year)

HeartSmart Patient Packet

CANCELLATION POLICY

APPOINTMENT PREPARATION INSTRUCTIONS

1) Demographics

2) Social History

Tobacco Use

Alcohol Use

3) Personal Medical History

Cardiovascular History

Genitourinary History

Ears, Nose, Mouth History

Endocrine History

Gastrointestinal

Head and Neck History

Musculoskeletal History

Skin History

Psychiatric History

Eye History

Neurologic History

Lung History

Miscellaneous Medical History

4) Weight / Dieting History

5) Past Surgeries, Procedures & Diagnostic Tests

6) Allergies

7) Medications

9) Family History

Sleepiness Scale

Stress Questionnaire

BHRT Symptom Survey

Female Phase of Life

Final Details