USF Health Cardiothoracic Surgery & Transplantation Robert Hooker, MD, Erol Belli, MD, John Dunning, MD, Riad Meada MD
Name:______Phone:______Address: ______City: ______State: ______Zip Code: ______Social Security #: ______- _____- ______Date of Birth: ____/_____/_____ Age: _____ Marital Status: ______Employment: ______E-mail Address: ______Emergency Contact:______Phone: ______Insurance Name:______Policy #:______Group #: _____ Name of Subscriber:______Date of Birth: ____/_____/_____ Relationship to Subscriber: ______
Primary Care Physician: Cardiologist/Pulmonologist:
Name:______Name:______
Address:______Address:______
Phone:______Phone:______
Fax:______Fax:______
Where you referred by your PCP or Cardiologist/Pulmonologist? If no, Please provide:
______
Reason for your visit: ______
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USF Health Cardiothoracic Surgery & Transplantation Robert Hooker, MD, Erol Belli, MD, John Dunning, MD, Riad Meada MD
Review of Systems (continue):
What Medications do you take? Please bring a list of Medications to your appointment.
Name of Medicine Dose(mg) How many times per day?
Allergies: ______
Past Medical History: [ ] High Blood Pressure [ ] Heart Murmur [ ] Valvular Heart Disease [ ] Coronary Artery Disease [ ] Emphysema [ ] High Cholesterol [ ] Asthma [ ] Heart Attack [ ] Ulcer [ ] COPD [ ] Kidney disease [ ] Gastric Reflux [ ] Liver Disease [ ] Diabetes [ ] Anemia [ ] Seizures [ ] Cancer [ ] Hernia [ ] Stroke [ ] Thyroid Disease [ ] Heart Rhythm Disorder
Other: ______
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USF Health Cardiothoracic Surgery & Transplantation Robert Hooker, MD, Erol Belli, MD, John Dunning, MD, Riad Meada MD
Past Surgical History: 1. ______Mon/Yr.: ______2. ______Mon/Yr.: ______3. ______Mon/Yr.: ______4. ______Mon/Yr.: ______5. ______Mon/Yr.: ______6. ______Mon/Yr.: ______7. ______Mon/Yr.: ______8. ______Mon/Yr.: ______
Cardiac Procedures: Date Hospital/ Clinic Echocardiogram:
Chest CT Scan/MRI: Heart Catheterization: Other:
Smoking History: [ ] Never smoked [ ] previous smoker- Quit smoking ____/_____ [ ] Smoke now- How often? ______
Alcohol History: [ ] Never Drink [ ] Previous Drinker – Quit drinking______/______[ ] Drink now- How often? ______Other Drugs:______
Social History: Who lives with you now? ______Who would be available to help you in the event of a major operation?
Work History: Occupation:______How many years?______
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USF Health Cardiothoracic Surgery & Transplantation Robert Hooker, MD, Erol Belli, MD, John Dunning, MD, Riad Meada MD
Family History: Relationship Cause of Death? High Blood Pressure [ ] ______Heart Murmur [ ] ______Coronary Artery Disease [ ] ______Emphysema [ ] ______Asthma [ ] ______Heart Attack [ ] ______Kidney Disease [ ] ______Liver Disease [ ] ______Diabetes [ ] ______Diabetes [ ] ______Seizures [ ] ______Cancer [ ] ______Stroke [ ] ______Thyroid Disease [ ] ______Other: ______
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USF Health Cardiothoracic Surgery & Transplantation
Robert Hooker, MD, Erol Belli, MD, John Dunning, MD, Riad Meada MD
Review of Systems
General: [ ] Weight gain [ ] Weight loss [ ] Weakness [ ] Fatigue
[ ] Fever [ ] None
[ ] Other ______
Eyes: [ ] Redness [ ] Tearing [ ] Dryness [ ] Double Vision
[ ] Cataracts [ ] Glasses [ ] Glaucoma [ ] Pain [ ] None
[ ] Other ______
Ears: [ ] Itching [ ] Vertigo [ ] Infections [ ] Decreased Hearing
[ ] Ringing [ ] Discharge [ ] Earaches [ ] None
[ ] Other______
Nose: [ ] Recent Cold [ ] Stuffiness [ ] Bleeding [ ] Discharge
[ ] Sinus Infection [ ] None
[ ] Other ______
Mouth: [ ] Gum Bleed [ ] Sore Throats [ ] Hoarseness [ ] None
[ ] Other ______
Cardiac: [ ] Chest Pain [ ] Murmur
[ ] Irregular Heartbeats [ ] Fainting
[ ] Palpitations [ ] None
[ ] Other ______
Pulmonary: [ ] Cough [ ] Sputum [ ] Wheezing
[ ] Asthma [ ] Shortness of Breath [ ] None
[ ] Other ______
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USF Health Cardiothoracic Surgery & Transplantation Robert Hooker, MD, Erol Belli, MD, John Dunning, MD, Riad Meada MD
GI: [ ] Constipation [ ] Nausea [ ] Heartburn [ ] Diarrhea [ ] Rectal Bleeding [ ] Vomiting [ ] None [ ] Other: ______Skin: [ ] Rashes [ ] Lumps [ ] Nail change [ ] Dryness [ ] Color change [ ] Sore [ ] Hair loss [ ] Itching [ ] None [ ] Other ______Neurological: [ ] Vertigo [ ] Numbness [ ] Weakness [ ] Tingling [ ] Black out spells [ ] Dizziness [ ] Headaches [ ] Tremors [ ] Seizure [ ] None [ ] Other ______Psychiatric: [ ] Anxiety [ ] Memory Loss [ ] Depressed [ ] Hallucinations [ ] Tension [ ] Nervousness [ ] None [ ] Other ______Urinary: [ ] Urgency [ ] Frequent urination [ ] Decreased Stream [ ] Blood in urine [ ] Incontinence [ ] None [ ] Other ______Blood: [ ] Bruising [ ] Gingival Bleeding [ ] Thin blood [ ] None [ ] Other ______Bone/Joint: [ ] Joint pain [ ] Backache [ ] Stiffness [ ] Gout [ ] Swelling [ ] None [ ] Other ______Endocrine: [ ] Heat intolerance [ ] Cold intolerance [ ] Frequent Hunger [ ] High Blood sugar [ ] Sweating [ ] Thirst [ ] None [ ] Other ______
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