Patient Information
Patient Name: ___________________________________, _________________________________, __________
Last
First
middle initial
Address: _____________________________________________________________________________________
Phones: _________________________, ______________________________, _____________________________
Home
Work
Sex: ___ Female ___ Male
Cell
Date of Birth: ____ / ____ / ____
Mo.
E-Mail: ___________________________________
Marital Status:
Single
Married
Day
Year
Primary Physician: ________________________________
Widowed
Divorced
Separated
Emergency Contact: ____________________________________________Phone#: __________________________
Relationship:
Father
Mother
Guardian
Sibling
Child
Other
Address: ___ same, If different: _____________________________________________________________________
Insurance Information:
Primary Insurance Company: ________________________________________ ID#: _______ ___________________
Group#: _______________________________________ Co-Payment: _____________________________________
Additional Insurance: ____________________________________________________ ID# ____________________
Assignment of Benefits:
I request that payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on
my behalf to Cape Regional Physicians Associates for any medical services provided to me. I understand that I am
financially responsible to the organization for any charges not covered by my health care benefits. I understand that it is
my responsibility to notify the organization of any changes in my health care coverage. I understand that by signing this
form I am accepting financial responsibility for all services received.
Privacy Notice Acknowledgment: By signing below, I acknowledge that I was provided access to Cape Regional’s Notice
of Privacy Practices.
Additional Information: (circle the applicable response)
Race: White, Black/African American, Asian, American Indian/Alaska Native, Native Hawaiian
Ethnicity: Hispanic/Latino, Not Hispanic/Latino, Prefer not providing.
Primary Language: English, Spanish, Other: _____________________________
Preferred Contact Number: Home, Work, Cell
Signature of patient or guardian
Printed name of patient or guardian
CRPA Cardiology
Date
Patient Name _________________________________________ Date of Birth ___________________________
New Patient – Cardiology Exam Form
Reason for Visit: ____________________________________________________________________________
Referred by/PCP Name: ______________________________________________________________________
Pharmacy:
Local ___________________________________ Mail ___________________________________
Do you have any questions for the doctor today?
________________________________________________________________________________________
________________________________________________________________________________________
Medications you currently take: (Include dose and strength)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Do you need any refills today? Yes / No
If Yes, please list:
________________________________________________________________________________________
________________________________________________________________________________________
Past Medical History of Patient: (Circle any medical problems)
Aneurysm
Hypertension
Angina
Hyperthyroid
Asthma
Hypothyroid
Cardiomyopathy
Kidney Disease
Connective Tissue Disease
Lupus
COPD
Peripheral Vascular Disease
Coronary Disease
Prior Heart Attack
Diabetes
Stroke
High Cholesterol
Allergies:
To Medications: __________________________________________________________________
To Foods/Other: __________________________________________________________________
Family History:
Mother – Is your mother alive? Yes / No
If No, what was her cause of death? __________________________________ Age at death? ________
Father – Is your father alive? Yes / No
If No, what was his cause of death? __________________________________ Age at death? ________
CRPA Cardiology
Patient Name _________________________________________ Date of Birth ___________________________
Check all that apply:
Atrial Fibrillation
Mom
Dad
Brother
Sister
Aneurysm
Mom
Dad
Brother
Sister
Coronary Artery Disease
Mom
Dad
Brother
Sister
CVA
Mom
Dad
Brother
Sister
Diabetes
Mom
Dad
Brother
Sister
Heart Disease
Mom
Dad
Brother
Sister
High Blood Pressure
Mom
Dad
Brother
Sister
High Cholesterol
Mom
Dad
Brother
Sister
Kidney Disease
Mom
Dad
Brother
Sister
Lung Disease
Mom
Dad
Brother
Sister
Peripheral Vascular Disease
Mom
Dad
Brother
Sister
Sudden Cardiac Death
Mom
Dad
Brother
Sister
Valvular Heart Disease
Mom
Dad
Brother
Sister
Social History:
Tobacco Use:
_____ Never Smoked
Total Years Smoked _____
Alcohol Use:
_____ Never
_____Current Smoker
Average packs per day _____
_____Former Smoker
When did you quit (age) _____
_____Occasional
Caffeine Use:
Yes / No
If Yes, cups per day: ____________________
Illicit Drug Use:
Yes / No
If Yes, specify: ________________________
Exercise: Do you exercise?
Yes / No
If Yes, type of exercise: ___________________________________
Frequency: ______________________________________
Surgical History: Have you had any surgeries?
(If applicable, circle any prior surgeries)
Yes / No
Appendectomy
Hysterectomy
Back Surgery
Open Heart Surgery
Bone (Knee, Hip or Other Surgery / Orthopedic Surgery
Thyroid surgery
Gallbladder Surgery
Vascular Surgery
Hemorrhoid Surgery
Other:__________________________
Hernia Surgery
CRPA Cardiology
Patient Name _________________________________________ Date of Birth ___________________________
Prior Cardiac Testing:
(Circle all that apply)
Cardiac Catheterization
Holter Monitor
ECHO
Stress Test
EKG
Other: ________________________________________
Review of Systems:
(Circle any symptoms you are CURRENTLY experiencing)
General
Change in appetite
Medication changes
Fatigue
Weight loss
Weight gain
Skin
Itching
Open areas
Rash
HEENT
Headache
Visual loss
Blurred vision
Snoring
Visual disturbances
Facial numbness/tingling
Respiratory
Cough
Shortness of breath
Chronic cough
Decreased exercise tolerance
Wheezing
Cardiovascular
Chest pain
Leg cramps
Chest pressure
Pain in legs at night
Difficulty breathing lying down
Pain in legs walking
Difficulty breathing on exertion
Palpitations
Difficulty breathing suddenly at night
Swelling of legs/ankles
Fainting/Blacking out
Gastrointestinal
Nausea
Bloody stool
Vomiting
Gets full quickly at meals
Diarrhea
Heartburn
Constipation
Poor appetite
Black tarry stool
Muskuloskeletal
Joint pain
Muscle pain
CRPA Cardiology
Muscle weakness
Skin changes
Patient Name _________________________________________ Date of Birth ___________________________
Neurological
Tingling
Dizziness
Numbness
Difficulty speaking
Weakness
Trouble walking
Weakness unilaterally (weakness on one side of the other)
Psychiatric
Anxiety
Depression
Panic attack
Easy bruising
Night sweats
Hematology
Abnormal bleeding
Signature of patient or guardian
Printed name of patient or guardian
CRPA Cardiology
Date
Record Release Authorization
NOTE: Bolded Sections to be completed by Cape Regional as needed for continuity of care purposes.
Patient should only provide name and date of birth and sign / date form. Thank you!
Facility: ________________________________________Fax#:___________________________________________
I hereby authorize you to release a copy of the medical records/information described below to:
Cape Regional Health System
Address: _______________________________________________________________________________________
Phone#: _________________________________________Fax#: _________________________________________
Requested Information: __________________________________________________________________________
Dates of Service: ________________________________________________________________________________
Date of Request: ________________________________________________________________________________
Patient Name: ________________________________________________ Date of Birth: _______________________
I understand that I have a right to revoke this authorization at any time. I understand that
If I revoke this authorization I must do so in writing. I understand that the revocation will not apply to information
that has already been released in response to this authorization. This authorization will remain in effect for a period
of one year from the date stated below unless revoked.
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this
authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the
information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information
carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal
confidentiality and privacy regulations.
Signature of patient or guardian
Printed name of patient or guardian
CRPA Cardiology
Date
Authorization to Share Health Information
Patient Name_______________________________________________ Date of Birth__________________________
Please indicate by your signature below if voicemail may be used to communicate Health Information with you and
your caregiver.
Signature ______________________________________________ Date _________________________________
Certain diagnoses require specific approval to release information. Please indicate by your signature below if we
have permission to communicate the following Health Information with your caregiver:
Alcohol or Drug Treatment/Counseling ___________________________________________________________
Psychological / Psychiatric Treatment
___________________________________________________________
STD, HIV, Hepatitis C or B Treatment
___________________________________________________________
Please provide the names of people with whom we may share your Health Information:
Name __________________________________ Relationship _______________ Phone #___________________
Name __________________________________ Relationship _______________ Phone #___________________
Signature ______________________________________________ Date __________________________________
The authority for this release will expire one year from this signature date.
Caregiver signature if patient is unable to sign _______________________________________________________
Witnessed ______________________________________________ Date _________________________________
Signature of patient or guardian
Printed name of patient or guardian
CRPA Cardiology
Date