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My Heart Spark - Patient Medical Records Summary

My Heart Spark - Patient Medical Records Summary

Thank you for completing this form to summarize external patient medical records that have come in for a potential, new, or established patient. Dr. Brown is thrilled to have you!
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    Welcome to My Heart Spark P.C.! Fill out this form below to summarize external patient medical records that have come in for a potential, new, or established patient. Please include as much details as you can. 

    After submitting this form, you will be taken to the electronic health records software login page in case you need to do anything else there.

    Thank you for caring for our patients, who need you!

     

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    Pick a Date
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    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
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    • Falkland Islands
    • Faroe Islands
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    • French Polynesia
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    • The Gambia
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    • Germany
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    • Greece
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    • Guadeloupe
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    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
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    • Hong Kong
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    • Iceland
    • India
    • Indonesia
    • Iran
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    • Ireland
    • Israel
    • Italy
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    • Jersey
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    • Kenya
    • Kiribati
    • North Korea
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    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    GLOSSARY

    Medical Records: To hopefully include the last full office visit note from primary care provider and/or heart doctor (if applicable). Please obtain and describe the contents of medical records from any clinicians and organizations that are available. Records should include notes on medical problems/past medical history and heart or blood vessel problems diagnosis (history and treatment information).


    Medical Imaging: To include results of the last 3 echo (ultrasound of the heart) with or without stress test, ECG (squiggly lines looking at electrical activity of the heart), chest X-ray, chest CT, heart MRI, nuclear/sestamibi/myocardial scan stress test, MUGA, brain/head/neck CT or MRI, and any other heart or chest imaging results documents; if possible, please provide from the past few years.


    Lab Tests: To include results documenting cholesterol, glucose, liver, kidney, blood cells, and other results checked and provided by primary care clinicians; if possible, please provide from the past few years.

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    The patient’s most recent/last ejection fraction (EF) was %, as reported on       dated    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s second most recent/second-to-last ejection fraction (EF) was %, as reported on       dated    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s third most recent/third-to-last ejection fraction (EF) was %, as reported on       dated    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent ECG showed , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s second most recent/second-to-last ECG showed , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s third most recent/third-to-last ECG showed , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent chest X-ray showed , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent chest CT showed , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent chest CT also showed atherosclerosis in the , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent chest CT also showed calcification in the , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent specifically “cardiac” or “coronary” CT/CTA or “calcium scan/study” also showed a total calcium score of , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent specifically “cardiac” or “coronary” CT/CTA or “calcium scan/study” also showed a calcium score of in the     , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent specifically “cardiac” or “coronary” CT/CTA or “calcium scan/study” also showed a calcium score of in the     , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent specifically “cardiac” or “coronary” CT/CTA or “calcium scan/study” also showed a calcium score of in the     , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent specifically “cardiac” or “coronary” CT/CTA or “calcium scan/study” also showed a calcium score of in the     , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent specifically “cardiac” or “coronary” CTA also showed , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent heart MRI showed , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent nuclear/sestamibi/myocardial scan stress test showed , with           as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent nuclear PET stress test showed , with               as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent cholesterol/lipid panel blood test showed Total Cholesterol       at   , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent cholesterol/lipid panel blood test showed LDL       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent cholesterol/lipid panel blood test showed HDL       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent cholesterol/lipid panel blood test showed Triglycerides       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent BUN blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent creatinine blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent AST blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent ALT blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent alkaline phosphatase blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent total bilirubin blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent direct bilirubin blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent glucose blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent HgbA1C blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent sodium blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent potassium blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent Hemoglobin (Hb) blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s second most recent/second-to-last Hemoglobin (Hb) blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s third most recent/third-to-last Hemoglobin (Hb) blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent troponin blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s second most recent/second-to-last troponin blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s third most recent/third-to-last troponin blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent/last NT-proBNP blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s second most recent/second-to-last NT-proBNP blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s third most recent/third-to-last NT-proBNP blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent/last creatine kinase (CK) blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s second most recent/second-to-last creatine kinase (CK) blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s third most recent/third-to-last creatine kinase (CK) blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent thyroid stimulating hormone (TSH) blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent (free) T4 blood test was       at , as reported on    Pick a Date    completed at (list institution/organization where test was completed) .

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    The patient’s most recent full office visit note from a primary care clinician at (list institution/organization where note was documented) dated    Pick a Date    showed       .

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    The patient’s most recent full office visit note from a cardiology clinician at (list institution/organization where note was documented) dated    Pick a Date    showed       .

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    The patient’s most recent full office visit note from a hematology or medical oncology clinician at (list institution/organization where note was documented) dated    Pick a Date    showed       .

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    The patient’s most recent full office visit note from a radiation oncology clinician at (list institution/organization where note was documented) dated    Pick a Date    showed       .

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    The patient’s most recent full office visit note from a surgical oncology clinician at (list institution/organization where note was documented) dated    Pick a Date    showed       .

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    The patient’s most recent full office visit note from a gynecologic oncology clinician at (list institution/organization where note was documented) dated    Pick a Date    showed       .

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    The patient’s most recent full office visit note from a       clinician at (list institution/organization where note was documented)
    dated    Pick a Date    showed       .

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    The following medical problems/past medical history and heart or blood vessel problems diagnoses (history and treatment information) that the patient has were listed on a note from a clinician dated    Pick a Date    at (list institution/organization where note was documented) .

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    The following medical problems/past medical history and heart or blood vessel problems diagnoses (history and treatment information) that the patient has were listed on a note from a clinician dated    Pick a Date    at (list institution/organization where note was documented) .

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    The following medical problems/past medical history and heart or blood vessel problems diagnoses (history and treatment information) that the patient has were listed on a note from a clinician dated    Pick a Date    at (list institution/organization where note was documented) .

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    The following medical problems/past medical history and heart or blood vessel problems diagnoses (history and treatment information) that the patient has were listed on a note from a clinician dated    Pick a Date    at (list institution/organization where note was documented) .

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    This is a fill in the field. Please add appropriate fields and text.

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    This is a fill in the field. Please add appropriate fields and text.

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    This is a fill in the field. Please add appropriate fields and text.

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    Fill out this form below to send us a detailed report of the patient's external medical records and also additionally fill out all the other sections of this form as best as you can
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    We will love to hear from you!
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    I consent to providing my contact and personal information in order to provide this patient external medical records summary report for My Heart Spark P.C.. I am aware that my information will only be used for these purposes. I attest that my electronic signature on this form is to have the same legally binding effect as my traditional handwritten signature. I am 18 years of age or older, and I am authorized to sign this form on my own behalf.
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    I understand that My Heart Spark P.C. (the “Practice”, “they”, “them”) provides this method of logging external medical records summary reports to help learn more about using such methods to support patients in protecting their heart. In the future, the Practice may want to look back on all of this to see whether this work has been helpful. When they look back at everything, they may want to capture summaries of all of the work. These summaries may involve combinations that have information I have entered here included in a way that is mixed with everyone else’s and cannot identify patients or me at all. If they look back at this work in this way in the future, they may call this “retrospective research” review. They may present and publish some of the combined and mixed results from this work, in a way that should not identify me since at least a few people are logging these medical records reports. This review would focus on understanding the effectiveness of these methods in efforts to help preserve heart health, so that they can better tailor services for the future. Through this research review, they may better understand and determine which methods are beneficial in helping patients build and maintain healthy heart habits. The research review committee will understand and respect the privacy of each and every individual. They would present and publish the combined and mixed information from their findings without disclosing my individual personal information in a way that could identify me. By signing below, I consent to my information being used as part of this future review. In the future, I can write them if I ever change my mind and would like my information removed from the combined and mixed results in their review. I attest that my electronic signature on this form is to have the same legally binding effect as my traditional handwritten signature. I am 18 years of age or older, and I am authorized to sign this form on my own behalf.
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