1-6 Month Follow Up Patient Packet

Garoutte Medical Associates, P.A

Max Garoutte, M.D. 1003 NE Loop 410 San Antonio, TX 78209 - 210-654-6000
Date

MonthDayYear
Date
Patient Last Name
Patient First Name
Signature
Reason for todays visit (Cath or CTA follow up? Hospital follow up? Dr. Garoutte requested follow up? Etc.):
Preferred Pharmacy Name & Pharmacy Address
Preferred Pharmacy Phone Number
Format: (000) 000-0000.
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 Dose/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 able to walk/jog on a treadmill, with significant incline (Please note, this will require significant physical exertion)
Please explain what circumstances inhibit you 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 the surrogate decision full maker's name and relationship to patient
Patient Date of Birth

MonthDayYear
Date
Have you recently had a Cath Procedure?
Please specify the date of your Cath Procedure

MonthDayYear
Date
Did your Cath Procedure require stents?
Have you experienced any post-procedure symptoms?
Please explain your post-procedure symptoms
Have you experienced any groin pain since the procedure?
Have you been experiencing any Chest Pain?
Please indicate the pain type as it relates to your chest pain:

Other
Does the chest pain radiate?
Where does it radiate?
Please indicate the location of the chest pain:
Please indicate the intensity of your chest pain (1 being slight pain & 10 being extremely severe pain)
When does the chest pain occur?

Other
Have you been experiencing Shortness of Breath?
Shortness of Breath is triggered or worsened by:
How would you describe the intensity of your shortness of breath
Do you use supplemental oxygen?
Liters Per Minute:
Please specify your supplemental oxygen use:
Have you been experiencing Palpitations?
During palpitations, the heart rate feels:
Indicate the location of the palpitations:
When do the palpitations occur?

Other
Do you experience abdominal pain?
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 does the Edema occur?
When did you have your most recent stroke/TIA?

MonthDayYear
Date
When were you diagnosed with Cardiac Arrhythmia?

MonthDayYear
Date
When were you diagnosed with Bradycardia?

MonthDayYear
Date
When were you diagnosed with Atherosclerotic Heart Disease

MonthDayYear
Date
When were you diagnosed with Rhematic Fever

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 Murmur?

MonthDayYear
Date
When were you diagnosed with Myocardial Infarction?

MonthDayYear
Date
When were you diagnosed with Peripheral Vascular Disease?

MonthDayYear
Date
Do you use a CPAP?
What is the brand of your pacemaker?
When was your pacemaker device 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 below:
Patient Signature certifying this form has been answered honestly and accurately:
Date

MonthDayYear
Date
Should be Empty:

Garoutte Medical Associates, P.A