New Patient Form: Heart Rhythm Clinic
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Insurance Referral
Website: https://ca.crissp.net/
Family or Friend's Recommendation
Other
How did you hear about us?
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Please Select
Insurance Referral
Website: https://ca.crissp.net/
Family or Friend's Recommendation
Other
Other: (Please specify)
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Today's Date:
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Patient's Name:
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Date of Birth: (MM-DD-YYYY)
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Social Security Number:
Gender:
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Marital Status::
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Address:
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REFERRING DOCTOR'S INFORMATION
Referring Doctor's Name:
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First Name
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Fax Number:
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PRIMARY CARE DOCTOR'S INFORMATION
Primary Care Doctor’s Name:
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First Name
Last Name
Address
Street Address
Street Address Line 2
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Contact Number:
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Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number:
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Format: (000) 000-0000.
PREFERRED PHARMACY INFORMATION
Pharmacy Name:
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Address
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Street Address
Street Address Line 2
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Postal / Zip Code
Phone Number
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Format: (000) 000-0000.
Fax Number
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Health Insurance Information
Primary Insurance Plan Name:
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Primary Insurance ID Number:
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Group Number:
Policy Holder:
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Self
Spouse
Child
Others
Policy Holder's Name:
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Policy Holder's Date of Birth:
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Social Security Number:
Relationship to Patient:
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Please upload or take a photo of your Insurance ID card (Back):
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Do you have a secondary insurance?
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Yes
No
Secondary Insurance Plan Name:
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Secondary Insurance ID Number:
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Group Number:
Policy Holder:
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Self
Spouse
Child
Others
Policy Holder's Name:
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Policy Holder's Date of Birth:
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Social Security Number:
Relationship to Patient:
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Please upload or take a photo of your Insurance ID card (Back):
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Other Insurance
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Not Applicable
Self Pay
Workers Compensation
Motor Vehicle Accident
Personal Injury
Other
Case Worker/Attorney Name:
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Case Worker/Attorney Phone Number:
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Date of Injury:
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Claim Number:
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Assignment and Release
I hereby authorize Crissp to bill my insurance carrier and assign benefits to be paid directly to the physician(s) at Crissp.
I understand that I am financially responsible for all non-covered services, copays, deductibles and/or coinsurance. I authorize and give consent for my provider to bill me directly for recommended services performed that are not covered under the terms of my health plan.
I authorize the physician to release any medical information required to process any claims.
I authorize my provider’s office to contact me by telephone to remind me of my appointments.
Signature
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Date
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Medical History
Why are you here today (problem)?
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(i.e. palpitations, chest pain, shortness of breath, heart racing, passing out, etc.)
What causes it:
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Walking
Exercise
Stress
Eating
Resting
Caffeine
Other
What describes your concern?
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Racing
Sharp
Dull
Aching
Pressure
Other
Severity:
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1
2
3
4
5
6
7
8
9
Most severe
10
1 is , 10 is Most severe
When did it start:
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Month
-
Day
Year
Date
Location of concern?
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What makes it worse or better?
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Modifying Factors
How long does it last?
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Duration
How often?
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(# of times day/week/month)
Other Heart Symptoms: (Please check if present)
Palpitations/Skipping Heart sensation
Chest pain/Pressure
Racing or Pounding Heart
Fainting / About to Faint
Shortness of Breath
Falls
Waking from Sleep w/shortness of breath
Swelling of ankles/legs
Shortness of breath while lying flat
Calf/Leg Pain
Have you seen another Physician for this problem?
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Yes
No
Who?
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Name of the physician
Location of office (city/state)?
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When (approximate date)?
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Have you ever been to a Cardiologist before?
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Yes
No
When (approximate date)?
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Why?
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Whom?
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Name of Cardiologist
Location of office (city/state)?
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Do you have any medical records that may assist us?
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Yes
No
Do you have any recent lab work in past 6 months?
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Yes
No
Pacemaker or Defibrillator History
Do you have a pacemaker or defibrillator?
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Yes
No
When was it implanted?
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Month
-
Day
Year
Date
What manufacturer?
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Abbott/St. Jude
Medtronic
Boston Scientific
Biotronik
Other
Does any office currently check it regularly?
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Approximately when was it last checked?
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Past Cardiovascular History:
Have you been diagnosed with an arrhythmia (abnormal heart rhythm)?
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Yes
No
If so, which one?
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How often do you have it?
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How long does it last?
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What makes it better?
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What makes it worse?
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Have you ever gone to ER for this?
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Yes
No
If so, when/which hospital?
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Which medications if any are you taking for this?
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Are you currently on a blood thinner?
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Yes
No
If yes, which one?
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Have you had any bleeding issues or needed to stop your blood thinner for any reason?
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Yes
No
If yes, why?
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Have you ever had an ablation? (An ablation involves catheters placed into your heart starting from your groin or neck, in order to treat an arrhythmia. This is different from a "cath" or angiogram, which looks for blockages in the blood vessels around your heart that may lead to a heart attack)
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Yes
No
If so, when?
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Month
-
Day
Year
Date
Name of doctor:
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Name of hospital/facility:
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Was it considered successful?
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Yes
No
Other
Have you ever had a cardioversion (electric shock to restore normal heart rhythm)?
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Yes
No
If so, when?
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-
Month
-
Day
Year
Date
Any previous blood vessel surgeries including for your legs?
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Yes
No
Do you or have you had any of the following? Please check if YES. (Risk Factors have *)
Heart Attack
Vascular Surgery
Heart Surgery (Any other not listed i.e valve)
Abnormal EKG
Aortic Aneurysm/Dissection
Hyperlipidemia (high cholesterol)
Cardiac Bypass Surgery (CABG)
Cardiomyopathy
Congenital Heart Disease (childhood)
Congestive Heart Failure
Coronary Artery Disease (Blocked Arteries)
Coronary Stent (PCI)
Deep Vein Thrombosis/DVT (leg blood clot)
Valve Stenosis (tight valve)
Valve Regurgitation (leaky valve)
Ventricular Septal Defect (VSD)
Hypotension (low blood pressure)*
Hypertension (high blood pressure)*
Murmur (extra heart sound)
Pericarditis
Pulmonary Embolism (lung blood clot)
Pulmonary Hypertension
Rheumatic Heart Disease
Stroke/ Cerebrovascular disease
Diabetes Mellitus (type I or type II)*
ANSWER IF APPLICABLE: Past Cardiac Testing History
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Rows
Yes
No
Date
Normal/Abnormal
24 hour Rhythm Monitor (Holter)
Normal
Abnormal
Event Monitor
Normal
Abnormal
Echocardiogram
Normal
Abnormal
Stress Test
Normal
Abnormal
Stress Echocardiogram
Normal
Abnormal
Stress Nuclear Test
Normal
Abnormal
Cardiac Catheterization
Normal
Abnormal
Electron Beam CT/Calcium Score
Normal
Abnormal
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Medications
Are you currently taking medications including non-prescription medications & herbal remedies?
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Yes
No
MEDICATIONS: List ALL medications that you are currently taking including non-prescription medications & herbal remedies. Or provide the office with a copy of your list of Medications.
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Rows
MEDICATION
DOSE
HOW
OFTEN?
APPROXIMATE
START
DATE
(MONTH AND
YEAR)
1
2
3
4
5
6
7
8
9
10
ALLERGIES OR SENSITIVIY TO MEDICATIONS:
Do you have any allergies?
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Yes
No
Allergies:
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Rows
Allergic to:
Severity:
1
Mild
Moderate
Severe
2
Mild
Moderate
Severe
3
Mild
Moderate
Severe
4
Mild
Moderate
Severe
GENERAL PAST MEDICAL HISTORY:
Please Check if Yes.
Asthma
Anemia
Anxiety
Arthritis
Autoimmune Disorder
Bleeding problems
Cancer
COPD/Lung disease
Depression
Gallbladder Stones/Disease
GI Bleed/Peptic ulcer disease/AVM
Gout
Hemorrhoids
Hepatitis (A or B or C)
HIV/AIDs
Thyroid Disease
Kidney Disease
Liver Disease
Liver Disease
Obesity
Osteoporosis
Seizures
Sleep apnea
Smoking (Tobacco)
Varicose Veins
Diabetes
Heart Failure
Heart attacks/heart blockages ("CAD")
Females only:
Gestational Diabetes
Menopause
Hysterectomy
Preeclampsia/Eclampsia
Ovaries Removed
Pregnancy Induced Hypertension
# of Pregnancies:
Males Only:
Erectile Dysfunction (ED)
Enlarged Prostate (Reduced Urine flow)/BPH
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PAST SURGICAL HISTORY
PAST SURGICAL HISTORY (MAJOR ONLY)
Rows
Year
Major Surgery
1
2
3
4
5
FAMILY HISTORY
Questions will pertain to only first-degree relatives (i.e. parents, brothers/sisters, and children) in your family. Questions will also pertain to age limits: Males 55 or younger, and females 65 or younger. Do any of your first-degree relatives have any of the following? Please check Y / N to the questions listed below, and if yes please explain relationship.
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Rows
Yes
No
Relationship w/ Family Member
Premature heart blockage or heart attack?
Heart failure or Cardiomyopathy?
Sudden cardiac death or unexplained death?
Abnormal heart rhythm?
Any other cardiac disease not yet mentioned?
Is your father alive?
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Yes
No
Age?
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If deceased, at what age?
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Cause if known:
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Is your mother alive?
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Yes
No
Age?
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If deceased, at what age?
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Cause if known:
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SOCIAL HISTORY
What is your occupation?
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Employer:
Employer's Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
# of Children: (put 0 if none)
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Do you or have you ever smoked (cigarette, cigar or pipe)?
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Yes
No
For how long (yrs)?
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How many per day?
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Did you quit?
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Yes
No
Non-smoking Tobacco (Chew/Snuff)?
Do you use Alcohol?
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Yes
No
how much/frequency? (Drinks/wk)
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0-5
6-10
>10
Have you ever used illicit drugs?
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Yes
No
What type and how long?
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Do you exercise?
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Yes
No
Type of exercise:
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How often: (Sessions/Week)
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0-3
4-7
How long are your exercise sessions?
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10-30mins
31-60mins
>60mins
Any special diet?
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(i.e. Dash, Adkins, low-fat, high-protein, low-salt ,etc.)
Do you add salt to food?
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Yes
No
Daily Caffeine?
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Yes
No
Daily Soft Drinks/ Sodas?
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Yes
No
REVIEW OF SYSTEMS
Please check the following symptoms that have occurred within the last 30 days. (Leave blank if negative)
Abdominal Pain
Anxiety
Balance Problems/Falls
Blood in Stool/Black Stool
Blood in urine
Blurred Vision/Doublevision
Clotting Disorder
Depression
Excessive Bruising
Fatigue
Fevers/Chills
Heartburn
Muscle pain/weakness
Nausea
Nose/Gum Bleeding
Poor Dental Health
Rash
Recent Weight Loss/Gain
Recurrent Headaches
Ringing in Ear/Tinnitus
Seizures
Sinus Problems
Slurred Speech
Snoring
Urination at night
Wheezing
Are you pregnant?
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