NPP SEC

Phone Numbers*

	Home	Cell	Work
Number

HIPAA Approved Contacts (Emergency Contacts)

Primary Insurance*

	Carrier	Policy #	Group #
Primary Insurance
Secondary Insurance

IF YOUR INSURANCE IS THROUGH YOUR SPOUSE, PLEASE PROVIDE THE FOLLOWING INFORMATION.

Spousal Insurance Information

	Name	DOB (mm/dd/yy)	SSN (xxx-xx-xxxx)
Spouse

Which Pharmacy do you use? (CVS on Hilton)*
Do you use a mail order pharmacy ? Which one?
Health History
Symptoms
Have you experienced any Chest Pain/Discomfort?*

YesNo
Have you experienced any Shortness of Breath?*

YesNo
Have you experienced any Palpitations?*

YesNo
Type a question*

No Past Medical HistoryAlcoholismCoronary Artery Disease (Stents or Bypass)Myocardial Infarction (Heart Attack)Congestive Heart FailureAneurysm (AAA)Aneurysm (Brain)Atrial FibrillationPeripheral Vascular DiseaseHeart MurmurHeart Valve IssuesHypertension (High Blood Pressure)Hyper cholesterolemia/HyperlipidemiaHypothyroidsimHyperthyroidismDiabetesKidney DiseaseCancerAsthmaBleeding DisorderBlood ClotsPulmonary EmbolsimStroke/TIAGERDHiatal HerniaCOPDSeizure DisorderSleep ApneaOther
Cancer Type

Allergies

Tobacco Use*

Never SmokedFormer SmokerCurrent SmokerVape/e-cigDip/Chew
Quit Smoking in Year
Packs per Day
Years Smoked
Alcohol Use*

Does Not DrinkDrinks Occasionally (<1-2 drinks/week)Drinks Regularly (>3 drinks/week)Heavy Alcohol Use (>14 drinks/week male >7 drinks/week female)
Recreational Drug Use*

No History of Recreational Drug UseFormer UseCurrent Use
Former Recreational Drug Use : Please Specify
Current Recreational Drug Use : Please Specify
Heart/Cardiovascular Surgical History

Coronary Stent PlacementCABG (Heart Bypass Surgery)Heart Valve SurgeryCardiac CatheterizationPacemaker PlacementWatchmanTAVRCardioversionAblation for Arrhythmia (A-fib ablation)Type Carotid Artery Surgery (Stenting or Endarterectomy)Peripheral Arterial Bypass or Stents (Leg Arteries)Aortic Aneurysm Repair (Abdominal or Thoracic)Other
Specific Heart Valve Surgery

Aortic ValveMitral ValveTricuspid ValvePulmonic Valve
Other Surgical/Procedural History

ColonoscopyEGD/ Upper EndoscopyBreast ImplantsHernia RepairCholecystectomy (Gallbladder Removal)HysterectomyMastectomy/LumpectomyBariatric Surgery (Gastric Bypass/ Sleeve)Lung Surgery (Lobectomy, Thoracotomy)Kidney Surgery (Transplant, Nephrectomy)Cancer Related SurgeryOrgan TransplantOther
Colonoscopy Most Recent Date (Month/Year)
EGD/Upper Endoscopy Most Recent Date (Month/Year)
Mastectomy/Lumpectomy Side

LeftRightBoth

Cardiology Family History

	Mother	Father	Siblings	Children	Grandparents
Coronary Artery Disease (CAD/MI)
Heart Failure/Cardiomyopathy
Arrhythmias (A-fib, VT, SVT)
Aortic Aneurysm/Disection

Please Read All the Consents and information
I acknowledge that I have read the above documents in their entirety and agree to comply with the requirements*

Yes
Signature*

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Symptoms