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
How did you hear about us?

Other
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.
Date of Birth

MonthDayYear
Date
Patient Current Age
Sex
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.
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
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
Are you physically able to walk/jog on a treadmill with significant incline? (Please note, this will require significant physical exertion)
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
Please indicate which of the following advanced directive applies to you:
Please provide non-surrogate decision maker's full name & relationship to patient
Have you been experiencing chest pain?
Please Indicate the pain type as it relates to your chest pain:

Other
Please indicate the onset of your chest pain:
Please indicate the occurrence of your most recent chest pain:
Please indicate the location of your chest pain:
Please indicate the interval of your chest pain:
Please indicate the intensity of your chest pain (1 being mild pain & 10 being extremely severe pain)
When does the chest pain occur?

Other
The chest pain is accompanied by:
Have you been experiencing Shortness of Breath?
Shortness of Breath is triggered or worsened by:

Other
How would you describe the intensity of your shortness of breath?
The shortness of breath is accompanied by:
Please indicate each of the following conditions you have a history of:
Do you use any of the following:
Have you been experiencing Palpitations?
During palpitations, the heart rate feels:
Indicate the location of the palpitations:
Please indicate the occurrence of your most recent palpitations:
Please indicate the intensity of the palpitations
When do the palpitations occur?

Other
Palpitations are accompanied by:
Do you use any of the following:
How much do you use?
Since your last appointment with our office, have you had any of the following:
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
Do you smoke, dip or vape tobacco?
Please indicate what tobacco product you use:
How much tobacco do you use?
How long have you been using tobacco products?
Are you a former tobacco product user?
How long ago did you quit using tobacco products?
Do you consume alcohol?
How many drinks per week?
Do you or have you ever used illicit drugs?
What illicit drugs?
When was the last time you used illicit drugs?
Are there any other symptoms you are experiencing you would like to discuss with Dr. Garoutte?
Please elaborate:
Please indicate which of the following cardiac risk factors you have been diagnosed with or treated for:
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
Do you use a CPAP machine?
Please indicate the brand of your pacemaker device:
When was your pacemaker implanted?

MonthDayYear
Date
Please indicate the reason your pacemaker was implanted:
Do you have difficulty with any of the following activities? (mark all that apply)
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
Date

MonthDayYear
Date
Should be Empty:

Garoutte Medical Associates, P.A.