Patient’s Name: _____________________________ Birth date ______/_____/_______ Age _________
Marital Status: (circle) Married Single Divorced
Widowed
Soc. Sec. # _______-______-_________
Street Address _____________________________City ________________ State ____ Zip _________
Home Phone # (______) _______-__________ Business Phone # (______) ______-__________
In case of emergency, who should be notified? __________________ Phone # (_____) ______-_______
How your emergency contact related to you? ___________________________
Are you currently?
Employed Unemployed Retired
Disabled
Student
Child
Name of employer ______________________ Employer Phone # (_____) _______-_________
Name of Spouse _______________ DOB: ________________ Spouse SS# ______________________
Spouse Employer ____________________________ Spouse Employer Phone # (_____) ______-_______
Primary Insurance Co. Name _________________________ Group # or ID # _____________________
Are you the Subscriber?
Yes/No If No, Subscriber’s Name: _________________________________
Secondary Insurance Co. Name _________________________ Group # or ID # _________________
Are you the Subscriber? Yes/No
If No, Subscriber’s Name: _________________________________
Referring Physician Name ________________________
Phone # (______) _______-__________
Family Physician Name __________________________
Phone # (______) _______-__________
Cardiologist Name _____________________________
Phone # (______) _______-___________
Please list other physicians who we should keep informed of your care.
Dr. _______________________ Specialty _________________
Phone # (_____) ______-_________
Dr. ________________________ Specialty _________________ Phone # (_____) ______-_________
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Cardiovascular and Thoracic Surgical Associates
Medical History
Patient Name: __________________________
MEDICATIONS: Prescriptions, Over the Counter Medications, Vitamins, Herbals, etc.
Name of Medication
Aspirin
Amount
How Often
Reason
ALLERGIES, ADVERSE/ALLERGIC DRUG REACTION
Medication or
Substance
Description of Reaction (e.g.,
Rash, Shortness of Breadth, etc.
Date of
Reaction
Comment
No Known Allergies
SOCIAL HISTORY
Tobacco use?
Never
Cigars
Cigarettes
Quit
Chewing Tobacco
Other
Packs Smoked per day?
Less than ½ pack/day
2 pack/day
½ pack/day
2 pack/day
1 pack/day
3 pack/day
1 ½ pack/day
more than 3 pack/day
# Years smoked?
_____________
Date you quit?
Alcohol use?
Never
Wine
Beer
Quit
Liquor
Other
Frequency ?
Occasional
Moderate
Heavy
Weekends Only
How many drinks/week?
_____________
________________
2
Cardiovascular and Thoracic Surgical Associates
Medical History
Patient Name: ___________________________
Drug use?
Marijuana
Other
Frequency ?
Occasional
Never
Prescription
Moderate
DO YOU EXERCISE?
Yes No
Quit
Heroin
Cocaine
Methamphetamine
Heavy
Weekends Only
Occasional
Moderate
Vigorous
FAMILY MEDICAL HISTORY (MOTHER, FATHER, BROTHER, SISTER)
FAMILY
MEMBER
HEART
DISEASE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
STROKE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
DIABETES
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
HIGH BLOOD
PRESSURE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
OTHER
ALIVE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
PAST MEDICAL HISTORY
Have you had or experienced any medical conditions listed below?
None
AIDS/HIV
Asthma
Blood Disease
Bowel Problems
Bronchitis
Chest Pain
Cancer
Diabetes
Emphysema
Emotional
Problems
Gynecologic
Disease
Heart Attack
High Blood Pressure
High Cholesterol
Heart Murmur
Hiatal Hernia
Hepatitis
Type: ___________
Kidney Disease
Lung Disease
Lupus
Liver Disease
Nervous System
Disorder
Prostate Disease
Pneumonia
Rheumatoid
Arthritis
Reflux/Indigestion
Stoke
Stomach Problems
Other
Scleroderma
Thyroid Disease
Ulcers
Vascular Disease
3
Cardiovascular and Thoracic Surgical Associates
Medical History
Patient Name: ___________________________
Have you experienced any of the following symptoms?
Persistent Fevers
no
yes
Discolored Urine
no
yes
Unexplained Weight Loss
no
yes
Bowel Bladder Problems
no
yes
Rashes
no
yes
Loss of Vision
no
yes
Joint Pain
no
yes
Anxiety or Depression
no
yes
Easy Bruising
no
yes
Hearing Loss
no
yes
Blood Clots in Legs/Lungs no
yes
Persistent Dizziness
no
yes
Miscarriage
no
yes
Difficulty Swallowing
no
yes
Skin or Hair Change
no
yes
Difficulty Talking
no
yes
Allergies
no
yes
Weakness in Arms or legs
no
yes
Sinusitis
no
yes
Numbness in Arms or Legs no
yes
Neck Pain
no
yes
Trouble Walking
no
yes
Low Back Pain
no
yes
Head Trauma
no
yes
Difficulty Breathing
no
yes
Headaches
no
yes
Palpitations
no
yes
Seizures
no
yes
Persistent Vomiting
no
yes
Memory Loss
no
yes
Persistent Diarrhea
no
yes
Trouble Sleeping
no
yes
Have you been exposed to: Asbestos Other toxic substance or hazardous chemical
Do you have pain? Yes
Pain Scale None
1
Where? _________________________________
2 3 4 5 6 7 8 9 10
PAST SURGICAL HISTORY
Have you ever had surgery?
Month
Year
Yes No
If yes, Please complete the questions below
Procedure/Hospitalization
Done at St. Luke’s
Yes
No
__________________________________________Date ____________
Physician Signature
__________________________________________Date ____________
Updated Physician Signature
__________________________________________Date ____________
Updated Physician Signature
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