Medical History
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Health Card number and version code
*
What is your Gender?
*
Male
Female
Height (_ft_in)
*
Weight (kg)
*
Do you have any medication allergies?
*
Yes
No
Not 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)
Diabetes
High blood pressure
High cholesterol
Heart disease
Are you a current cigarette smoker?
Please Select
Yes
No
Please select if you RECENTLY had:
*
Chest pain or pressure with EXERCISE
Chest pain or pressure with STRESS
Chest pain or pressure AT REST
Palpitation, irregular heartbeats, fast or slow heart rates
Fainting or near fainting or dizziness
Swelling of your legs
Leg pain or cramps when walking
Please select if you have EVER had:
*
Heart attack/MI (myocardial infaraction)
Angina
Heart Murmur
Rheumatic Fever
Congestive heart failure or heart enlargement
Atrial fibrillation/irregular heart beat
Kidney failure or on hemodialysis
Heart Valve surgery
Coronary bypass surgery
Fainting spells
Autoimmune conditions
Thyroid disease
Have you had any of the following (Please select all that applies):
*
A stress test
An Echocardiogram
A Heart Catheterization or angioplasty, or stent
A Pacemaker or debribillator
Heart bypass, coronary, or valve surgery
Are you currently taking any medication?
*
Yes
No
Please list all prescribed medications (include dosage and frequency)
*
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
How often do you consuming tabacco?
Half a pack per day
Full pack per day
More than 1 pack per day
Only social occasion
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
How often do you consume alcohol?
1-5 alcoholic beverage per week
6-10 alcoholic beverage per week
More than 10 alcoholic beverage per week
Only social occasion
Save
Submit
Should be Empty: