DIVISION OF CARDIOLOGY
HEALTH QUESTIONNAIRE
The University of Mississippi Medical Center request this information for the purpose of providing patient care.
No persons outside UMMC are provided this information without your consent. If you fail to provide this
information, patient care may be impaired.
If you have questions or need help completing this form, please ask for help.
PERSONAL HISTORY: Check beside any of the following that YOU have had:
Anemia
Arthritis
Asthma
Blood Clots/ bleeding problems
Cancer
Carotid Artery Disease
Chicken Pox
Congestive Heart Failure
Depression
Diabetes
Emphysema
Gallstones
Heart Attack
Heart Defect (from birth)
Heart Murmur
High Blood Pressure
Kidney Disease
Migraines
Peripheral Vascular disease
Pneumonia
Polio
Rheumatic Fever
Scarlett Fever
Seizures
Stroke
Stomach Ulcer
Thyroid Disease
Tuberculosis
ALLERGIES TO MEDICATIONS:
Type of reaction:
PERSONAL HABITS: please circle all that apply
Tobacco: Do you now or have you ever used tobacco products?
If yes, what type?
Cigarettes
Pipe
Yes
No
Cigars
Smokeless tobacco (chew)
/ per day
For how many years?
Never
Snuff
Vapor smoke
When did you quit?
How much do / did you smoke? #
Drug Use: Do you now or have you ever used any non-medical drugs?
Yes
No
Never
Beer
Wine
What type of drug?
Alcohol Use: Do you drink alcohol?
How much? #
Yes
Liquor
Yes
No
If yes, what type? Coffee Soda
Tea
drinks per day / week / month (circle one)
Exercise: Do you exercise regularly?
How often?
If yes, what type?
drinks per day / week / month (circle one)
Caffeine: Do you drink caffeinated drinks?
How much? #
No
Yes
No
If yes, what type?
days per week
Please continue on next page
Family History: Review the problem list below and check YES if any of your blood relatives have ever had the
problems listed below. This includes mother, father, brother, sister, son, daughter, mother’s parents or father’s parents.
Problem
Asthma
Cancer
Congestive Heart Failure
Diabetes
Heart Attack
Heart birth defect
Heart murmur
Other problem
Y
N
Relative
Problem
High Blood Pressure
Kidney Disease
Seizures
Stroke
Sudden Death
Thyroid Disease
Tuberculosis (TB)
Y
N
Relative
Surgical History: Check YES if you have ever had any of the surgeries listed below. Please add any other procedures
in the space below.
Sugery
Ablation for Irregular
heart rhythm
Abdominal aortic
aneurysm repair
Appendectomy
Carotid artery surgery
Cataract surgery
Colon surgery
Electrophysiology study
Gallbladder surgery
Heart bypass surgery
Heart catheterization
Other surgeries:
Y
N
Year / Other info
R / L / Both
R / L / Both
Surgery
Heart valve
replacement
Hernia surgery
Y
N
Hip replacement
Hysterectomy
Knee replacement
Mastectomy
Shoulder surgery
Stent placement
Tonsilectomoy
Vascular surgery
Year / Other info
Which valve?
R / L / Both
R / L / Both
R / L / Both
Review of Symptoms: Review the problem list below and check YES if you are having the problem. Check no if you are
not having the problem. Please check a box for each problem listed.
Problem
Fever / Chills
Night sweats
Weight loss / gain
Fatigue
Erectile dysfunction
Lump / swollen glands
Frequent/severe
headaches
Vision problems
Ear/hearing problems
Cough
Shortness of breath
Wheezing
Chest pain / pressure
Palpitation /heart racing
Swelling in ankles/ feet/
hands
Y
N
Comments
Problem
Heartburn
Decreased appetite
Difficulty swallowing
Abdominal pain
Constipation
Diarrhea
Bloody or black stools
Y
N
Change in bowel habits
Nighttime urination
Joint pain / stiffness
Easy bruising / bleeding
Fainting spells
Dizziness
Seizures
Pain in calves while
walking
I verify that this information is correct.
Patient signature:
Date
Comments