Patient History

edical History and Pre-Registration Form

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Cardiac

* Do you have high blood pressure?
* Have you ever had a heart attack?
* Have you ever had open heart surgery?
* Have you ever had cardiac angioplasty?
* Do you have a heart stent?
* Do you have a weak or failing heart?
* Do you have an irregular heartbeat or heart rhythm?
* Do you have a heart nurmur or mitral valve prolapse?
Have you ever had a heart valve replacement?
* Do you have a pacemaker?
* Do you have a implanted defibulator device?
* Have you ever been told that you have a widening of your aorta or that you have an aortic aneurysm?
* Have you ever been told you have peripheral vascular disease?
* Have you ever had a stress test?
* Have you ever had a cardiac echo test?
* Have you ever had a heart catheterization?

Pulmonary

* Do you smoke?
* Do you have a history of asthma?
* Do you have a history of chronic bronchitis?
* Do you have a history of emphysema?
* Have you had any recent colds, fever or flu symptoms?
* Do you have difficulty breathing or wheezing?
* Do you use supplemental oxygen?

Endocrine System Review

* Do you have diabetes?
* Do you have thyroid problems?
* Do you have kidney/renal problems?
* Are on on dialysis?
* Do you have liver problems?
Have you ever had Hepatitis?
* Do you have heart burn?

Social Habits of the Patient

* Do you drink alcohol every day?
* Do you use recreational drugs?