USF Health Cardiothoracic & 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 : 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 & 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 Dose(mg) How many times per day?

Allergies: ______

Past Medical History: [ ] High Blood Pressure [ ] Murmur [ ] Valvular Heart Disease [ ] [ ] Emphysema [ ] High Cholesterol [ ] Asthma [ ] Heart Attack [ ] Ulcer [ ] COPD [ ] Kidney disease [ ] Gastric Reflux [ ] [ ] Diabetes [ ] [ ] Seizures [ ] [ ] Hernia [ ] [ ] 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 / 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 [ ] [ ] Decreased Hearing

[ ] Ringing [ ] Discharge [ ] Earaches [ ] None

[ ] Other______

Nose: [ ] Recent Cold [ ] Stuffiness [ ] Bleeding [ ] Discharge

[ ] Sinus [ ] None

[ ] Other ______

Mouth: [ ] Gum Bleed [ ] Sore Throats [ ] Hoarseness [ ] None

[ ] Other ______

Cardiac: [ ] 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 [ ] [ ] None [ ] Other ______

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