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. 👇

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  • 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.

  • 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. 

  • 1) Demographics

  • Date
     - -
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Biological Gender*
  • Can we send you email communication?*

  • 2) Social History

  • Marital Status*
  • Living*
  • Heritage*
  • Do you get 30 minutes of steady physical exertion/exercise 3-4 times per week?*
  • What kind of physical exercise?*
  • Do you have physical conditions that limit your ability to exercise?*

  • Tobacco Use

  • *
  • What kind of tobacco?*

  • Alcohol Use

  • Do you drink alcohol?*
  • Has any blood relative of yours had a heart attack or stroke before the age of 60?*
  • Have you ever had a heart attack, stroke, stent, cath lab procedure involving your heart?*

  • 3) Personal Medical History

    Check any of the conditions that you currently have or have had in the past. Please explain if the answer is "yes."

  • Cardiovascular History

  • High blood pressure*
  • High cholesterol*
  • Diabetes*
  • Heart Failure*
  • Heart Murmur*
  • Chest pain or Angina*
  • Heart skips a beat*
  • Heart beats too fast*
  • Passing out spells*
  • Rheumatic fever*
  • Feet, ankle or leg swelling*
  • Short of breath at rest*
  • Short of breath with exercise*
  • Short of breath lying down*
  • Problems sleeping*
  • Sexual dysfunction*
  • Frequent urination*
  • Abdominal pain*

  • Genitourinary History

  • Burning or painful urination*
  • Blood in urine*
  • Bladder infections*
  • Incontinence, dribbling*
  • Kidney stones*
  • Irregular menses (female only)*

  • Ears, Nose, Mouth History

  • Loss of smell*
  • Nose bleeds*
  • Sinus problems*
  • Runny nose*
  • Postnasal drip*
  • Earache or drainage*
  • Hearing loss*
  • Ringing in ears*
  • Sores in mouth*

  • Endocrine History

  • Night sweats*
  • Excessive thirst*

  • Gastrointestinal

  • Rectal bleeding*
  • Blood in stool*
  • Loss of appetite*
  • Heartburn or indegestion*
  • Black or tarry stools*
  • Frequent diarrhea*
  • Difficulty swallowing*
  • Nausea or vomiting*
  • Vomiting of blood*
  • Chronic constipation*
  • Stomach ulcer*

  • Head and Neck History

  • Swelling in neck*
  • Prolonged hoarseness*
  • Frequent sore throat*
  • Pain or stiffness in neck*

  • Musculoskeletal History

  • Swollen or red joints*
  • Poor leg circulation*
  • Arm or leg weakness*
  • Leg cramps*
  • Difficulty in walking*
  • Arthritis*
  • Inflammatory Disease (psoriasis)*

  • Skin History

  • Rash, dryness, itching*
  • Change in nails or skin color*
  • Bleeding, bruising tendencies*

  • Psychiatric History

  • Depression*
  • Anxiety*
  • Nervous breakdown*
  • Alcohol problems*
  • Physical, verbal, sexual abuse*

  • Eye History

  • Glasses or contacts*
  • Double, failing vision*
  • Dry eyes*
  • Pain or light sensitivity*

  • Neurologic History

  • Light headed or dizziness*
  • Speech disturbances*
  • Convulsions or seizures*
  • Numbness or tingling*
  • Frequent headaches*
  • Memory loss*
  • Paralysis or weakness*

  • Lung History

  • Cough with sputum or blood*
  • Wheezing*
  • Asthma*

  • Miscellaneous Medical History

  • Fever or chills*
  • Recent weight change*
  • Fatigue*
  • Heat or cold intolerance*
  • Recent changes in mood*

  • 4) Weight / Dieting History

  • Do you want to change your eating habits?*
  • Are members of your family overweight?*

  • 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"
  • Is this a current problem?*
  • Date of test/surgery*
     - -
  • Is this a current problem?*
  • Date of test/surgery*
     - -
  • Is this a current problem?*
  • Date of test/surgery*
     - -
  • Is this a current problem?*
  • Date of test/surgery*
     - -

  • 6) Allergies

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

  • List allergies and type of reaction. Include medications, food, and seasonal/environmental allergies (animals, latex, smoke, etc.)

  • 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.

  • 9) Family History

    Please complete this section to the best of your ability. If you don't know, that's okay.
  • Are you adopted?*
  • High blood pressure
  • High Cholesterol
  • Diabetes (type 1 or 2)
  • Heart Attack
  • Heart Failure
  • Heart surgery/stent/balloon
  • Leg circulation problem
  • Failing kidneys
  • Stroke
  • Dementia/Alzheimer's
  • Alcoholism
  • Arthritis
  • Birth Defects
  • Sudden Death
  • Genetic Diseases

  • Sleepiness Scale

  • How likely are you to doze off or fall asleep in the situations described below, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you haven't done some of these activities recently, consider how they would have affected you.

  • Sitting and reading*
  • Watching TV*
  • Sitting and talking to someone*
  • Sitting quietly after a lunch without alcohol*
  • Sitting, inactive in a public place (e.g. a theatre or in a meeting)*
  • As a passenger in a car for an hour without a break*
  • Lying down to rest in the afternoon when circumstances permit*
  • In a car, while stopped for a minutes in the traffic*

  • Stress Questionnaire

  • Heart pounding or racing*
  • Trembling/shaking*
  • Grinding of teeth (even in your sleep)*
  • Do not sleep well*
  • Susceptible to illness*
  • Stomach pains*
  • Headaches*
  • Migraine headaches*
  • Feeling tired constantly*
  • Constipation*
  • Hollow stomach*
  • Lowered self-confidence*
  • Loss of appetite*
  • Excessive sweating (e.g. hands, face, armpits etc.)*
  • Sweaty palms*
  • Listlessness - don't feel like don't stuff*
  • Forget things*
  • Absent-minded*
  • Feeling irritated*
  • Nauseous*
  • Considered suicide*
  • Pessimistic*
  • Jealous/Envious*
  • Moody*
  • Pain in lower back*
  • Feelings of depression*
  • Anxiety*
  • Loss of interest in things*
  • Sensitive and/or touchy*
  • Muscle pain*
  • Indecisive*
  • Unnecessary/excessive checking of work*
  • Difficulty with breathing*
  • Struggle to overcome minor illness (e.g. a cold)*
  • Suspicious*
  • Wasting time on irrelevant activities*
  • Cannot discuss my problems with others*
  • Hair loss*
  • Throat irritations*
  • Lost sense of humor*
  • Impaired concentration*
  • Struggle to lose/gain weight even when following a diet*
  • Heartburn*
  • Skin disorders*
  • Don't take the initiative you used to*
  • Nightmares*
  • Dry mouth*
  • Consumption of energy drinks (Red Bull, 5-hour energy etc.)*
  • Diarrhea*
  • Nervous twitches in face and scalp*
  • Feelings of inadequacy*
  • Easily startled/jumpy*
  • Increased appetite*
  • Impaired coordination*
  • Uncertainty*
  • Become frustrated quickly*
  • Less involvement with others*
  • Biting of fingernails*
  • Reduced motivation*
  • Increased caffeine intake (coffee, tea, soda etc.)*
  • Restlessness*
  • Poor judgement*
  • Increased smoking*
  • Feeling out of control*
  • Confused thoughts*
  • Increased time sleeping*
  • Use tranquilizers, sleeping pills*
  • Wake up tired*
  • Feeling overwhelmed by demands*
  • Excessive blinking*
  • Daydreaming*
  • Procrastination*
  • Feeling panicky*
  • Difficult to identify causes of nonperformance*
  • Reduced productivity*

  • BHRT Symptom Survey

  • Energy*
  • Sleep*
  • Mood (depression, stress, anxiety)*
  • Pain*
  • Joint or muscle pain*
  • Depressed mood or anxiety*
  • Declining mental ability / focus / concentration*
  • Mood changes / irritability*
  • Decreased muscle strength*
  • Migraine headaches*
  • Decreased libido / desire*
  • Difficulty in sexual performance / climax*
  • Rapid hair loss*
  • Skin changes / dry or wrinkled skin*
  • Swelling or bloating*
  • Weight gain / unable to lose weight*
  • Intimacy dryness*
  • Hot flashes or night sweats*
  • Breast tenderness*

  • Female Phase of Life

  • Date of last menstrual period (can be estimated)*
     - -
  • Menopause*

  • Final Details

  • How Did You Hear About Us?*
  • Would you like us to send your results to another health care provider?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Should be Empty: