6 Month+ Follow Up Patient Packet

Garoutte Medical Associates, P.A.

Max Garoutte, M.D. 1003 NE Loop 410 San Antonio, TX 78209
Date

MonthDayYear
Date
Friend/FamilyOnlineOther
Referring Physician (Surgeon, if applicable)
Referring/Surgeon Phone Number
Primary Care Physician (clinician who manages your medications)
Primary Care Physician Phone Number
Patient Last Name*
Patient First Name*
Patient Middle Name
Reason for Todays Visit (Physician referral/recommended? Abnormal EKG? Pre-Op Clearance? Cardiac Symptoms? Get (re)established with a cardiologist? Etc.)
All consultations, follow ups & new patient appointments consist of meeting with the clinician & possibly an EKG. Cardiac testing appointments and cardiac clearance occurs on a separate dates from your initial consultation. We do not have the ability to complete same day testing.

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Date of Birth*

MonthDayYear
Date
Patient Current Age*
MaleFelmalePrefer not to specify
Address*
City
State
Please use the 2 character State Abbreviation
Zip
Patient Cell Phone #*
Format: (000) 000-0000.
Patient Home Phone #
Format: (000) 000-0000.
Email*
example@example.com
Social Security
Emergency Contact Name & Relationship to Patient
Emergency Contact Phone #
Patient authorizes the release of medical information to: (please print the name of the authorized individual and relationship to patient). If you do not wish to release medication information, please input "None" in the space below.
Primary Insurance Provider. If self pay/private pay/cash pay please input "Private Pay" in the blank below:
Primary Insurance Member ID #
Primary Insurance Group #
Secondary Insurance Provider
Secondary Insurance Member ID #
Secondary Group ID
Patient is required to bring all current insurance cards AND valid photo ID to their appointment. Please sign below acknowledging you understand that failure to bring insurance card and ID may result in delays or rescheduling of your appointment.

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Preferred Pharmacy Name & Address*
Preferred Pharmacy Phone Number*
What Medications are you allergic to? If none, please input "None" in the space below:*
List ALL prescription medications that you are currently taking. Also list vitamins, minerals, and over the counter medications such as Tylenol, Advil, Laxatives, Allergy Medicine, etc MedicationDose/Mg/Unit Frequency

**Please Note, If your medication list exceeds 8 medications, you may upload a copy of your medication list below (please do not upload pictures of your medication bottles), or you may skip this section AND bring a completed list of all medications (with dosages and frequency) to your appointment**

Dr. Garoutte cannot see you without an updated medication list.
Please provide a signature acknowledging that you have read and understand the medication-list instructions. If you have any questions, feel free to contact our office at 210-654-6000*

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You may submit a copy of your medication list here.

Medication list upload
Cancelof
Medication/Supplement/Vitamin #1
ENTER ONLY ONE MEDICATION IN THE FIELD
Dose/Mg/Unit #1
Frequency #1
Reason for taking medication #1
Medication/Supplement/Vitamin #2
ENTER ONLY ONE MEDICATION IN THE FIELD
Dose/Mg/Unit #2
Frequency #2
Reason for taking medication #2
Medication/Supplement/Vitamin #3
ENTER ONLY ONE MEDICATION IN THE FIELD
Dose/Mg/Unit #3
Frequency #3
Reason for taking medication #3
Medication/Supplement/Vitamin #4
ENTER ONLY ONE MEDICATION IN THE FIELD
Dose/Mg/Unit #4
Frequency #4
Reason for taking medication #4
Medication/Supplement/Vitamin #5
ENTER ONLY ONE MEDICATION IN THE FIELD
Dose/Mg/Unit #5
Frequency #5
Reason for taking medication #5
Medication/Supplement/Vitamin #6
ENTER ONLY ONE MEDICATION IN THE FIELD
Dose/Mg/Unit #6
Frequency #6
Reason for taking medication #6
Medication/Supplement/Vitamin #7
ENTER ONLY ONE MEDICATION IN THE FIELD
Dose/Mg/Unit #7
Frequency #7
Reason for taking medication #7
Medication/Supplement/Vitamin #8
ENTER ONLY ONE MEDICATION IN THE FIELD
Dose/Mg/Unit #8
Frequency #8
Reason for taking medication #8
YesNo
Please explain what circumstances inhibit your from walking/jogging on a treadmill with significant incline?
Date of most recent Covid diagnosis/positive test

MonthDayYear
Date
Do not intubateDo not resuscitateNon-surrogate decision makerNone of the above
Please provide non-surrogate decision maker's full name & relationship to patient
YesPatient denies chest pain
AchyBurningTightnessSharpPressureIndigestion-LikeOther
SuddenGraduallyIntermittently (comes and goes)
TodayDays agoWeeks agoMonths agoMore than 6 months ago
Center of chestLeft side of chestRight side of chestNeck/JawRight ArmLeft ArmShooting Across ChestMid-EpigastricBetween shoulder blades
ContinuousIntermittentAcuteChronic
12345678910
While SleepingAt RestWith Physical ExertionWhen StressedWith PalpitationsOther
Fainting/DizzinessHeadacheNauseaRapid/Irregular Heart RateShortness of BreathFatigueSweating
YesPatient denies shortness of breath
RestExertionWalkingWhen StressedSmokingOther
MildModerateSevere
Chest Pain/TightnessRapid/Irregular Heart RateFaint/DizzinessSweatingFatigue/WeaknessRight Leg/Foot SwellingLeft Leg/Foot Swelling
AsthmaCOPDEmphysemaSupplemental OxygenAtrial FibrillationCardiac ArrhythmiaSleep Apnea
CPAPAutoPAPMouthguardPacemaker
YesPatient denies palpitations
Faster than normalSlower than normalIrregular/UnsteadyFluttersSpasmsFlip/Flop
Right side of chestLeft side of chestThroat
TodayDays AgoWeeks AgoMonths AgoMore than 6 Months Ago
MildModerateSevere
At RestDuring/After ExertionWhen StressedWhile Laying/SleepingOther
Chest Pain/DiscomfortShortness of BreathDizziness/Lightheadedness
SteroidsInhalersNebulizer TreatmentsCaffeine
How much do you use?
Right Knee SurgeryLeft Knee SurgeryBack SurgeryRight Hip SurgeryLeft Hip SurgeryNone of the above
When was your knee surgery?

MonthDayYear
Date
What part of your back?
When was your back surgery?

MonthDayYear
Date
When was your hip surgery?

MonthDayYear
Date
YesNo
Please indicate what tobacco product you use:
How much tobacco do you use?
How long have you been using tobacco products?
YesNo
How long ago did you quit using tobacco products?
YesNo
How many drinks per week?
YesNo
What illicit drugs?
When was the last time you used illicit drugs?
YesNo
Please elaborate:
DizzinessFatigueEdemaStroke/TIAHigh Blood PressureDiabetesHigh CholesterolKidney DiseaseAtherosclerotic Heart DiseaseBradycardiaCardiac ArrhythmiaCOPDCongestive Heart FailureMurmurMyocardial InfractionPeripheral Vascular DiseaseRheumatic FeverSleep ApneaPacemakerNone of the above
When were you diagnosed with edema?

MonthDayYear
Date
Where did/does the edema occur?
When did the stroke/TIA occur?

MonthDayYear
Date
When were you diagnosed with Atherosclerotic Heart Disease?

MonthDayYear
Date
When were you diagnosed with Bradycardia?

MonthDayYear
Date
When were you diagnosed with Cardiac Arrhythmia?

MonthDayYear
Date
When were you diagnosed with COPD?

MonthDayYear
Date
When were you diagnosed with Congestive Heart Failure?

MonthDayYear
Date
When were you diagnosed with Heart Mumur?

MonthDayYear
Date
When were you diagnosed with Myocardial Infarction?

MonthDayYear
Date
When were you diagnosed with Peripheral Vascular Disease?

MonthDayYear
Date
When were you diagnosed with Rheumatic Fever?

MonthDayYear
Date
YesNo
Please indicate the brand of your pacemaker device:
When was your pacemaker implanted?

MonthDayYear
Date
Please indicate the reason your pacemaker was implanted:
WalkingStanding for long periods of timeWalking up or down stairsNone of the above
Please list all surgeries (from birth to present) including approximate date. If none, please input "None" in the space below:*
I certify that the answers on this form have been answered honestly and accurately to the best of my ability I also acknowledge by signing this form I am consenting to receive care from Garoutte Medical Associates. Type full name and sign below:*
Patient Signature

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Date

MonthDayYear
Date
Should be Empty:

Garoutte Medical Associates, P.A.