Pre-Visit Medical Form

Medical History
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Health Card number and version code *
What is your Gender?*

MaleFemale
Height (_ft_in)*
Weight (kg)*
Do you have any medication allergies?*

YesNoNot Sure
Please list any allergies
Family Doctor
Pharmacy
Current complaints? (Please answer in detail)
Have you ever seen a Cardiologist before? (When and who)
Have you ever been diagnosed with: (Please select all that apply)

DiabetesHigh blood pressureHigh cholesterolHeart disease
Are you a current cigarette smoker?
Please select if you RECENTLY had:*

Chest pain or pressure with EXERCISEChest pain or pressure with STRESSChest pain or pressure AT RESTPalpitation, irregular heartbeats, fast or slow heart ratesFainting or near fainting or dizzinessSwelling of your legsLeg pain or cramps when walking
Please select if you have EVER had:*

Heart attack/MI (myocardial infaraction)AnginaHeart MurmurRheumatic FeverCongestive heart failure or heart enlargementAtrial fibrillation/irregular heart beatKidney failure or on hemodialysisHeart Valve surgeryCoronary bypass surgeryFainting spellsAutoimmune conditionsThyroid disease
Have you had any of the following (Please select all that applies):*

A stress testAn EchocardiogramA Heart Catheterization or angioplasty, or stentA Pacemaker or debribillatorHeart bypass, coronary, or valve surgery
Are you currently taking any medication?*

YesNo
Please list all prescribed medications (include dosage and frequency)*
Do you use or do you have history of using tobacco?*
How often do you consuming tabacco?

Half a pack per dayFull pack per dayMore than 1 pack per dayOnly social occasion
Do you use or do you have history of using illegal drugs?*
How often do you consume alcohol?

1-5 alcoholic beverage per week6-10 alcoholic beverage per weekMore than 10 alcoholic beverage per weekOnly social occasion
Should be Empty:

Medical History