| PATIENT |
PHYSICIAN |
| |
| Why are you here to see a cardiologist? |
CC |
| |
|
| Check off any heart problems or symptoms |
HPI Elements: Locations, qualilty,severity,duration,timing, |
| Heartattack |
context,modifying factors, associated signs and symptoms. |
| Angina |
|
| High Blood Pressure |
|
| Heart Murmur |
|
| Rheumatic Fever |
|
| Abnormal Rhythum(arrhythmia) |
|
| Palpitations, irregular heartbeats |
|
| Fainting |
|
| Enlarged Heart |
|
| Chest Pains or Pressure |
|
| Shortness of Breath |
|
| Dizziness |
|
| Swollen Legs |
|
| Heart Failure |
|
| Blue Lips or Fingernails |
|
| Leg Cramps When You Walk |
|
| Have you ever had: | |
| A Stress Test |
|
| An Echocardiogram |
|
| Cardiac Catheterizaton/ Heart Catheterization |
|
| Coronary Bypass Surgery |
|
| Valve Surgery |
|
| An Electrophysiology Study or Procedure |
|
| A Pacemaker or Defibrillator |
|
| Tell us about your risk of heart disease | |
| Please check if you have: | |
| High Blood Pressure |
|
| High Cholesterol |
|
| Ever Smoked |
|
| Diabetes |
|
| Do you exercise (including walking)? | |
| | |
Had a close family member had a heart attack, angina or
bypass surgery? | |
| Who ? | |
| If you are a women, have you passed menopause
(change of life)? | |
| At what age? | |
| Dou you take estrogen replacement? | |
| Please tell us anything else about your heart : | |
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