Last name	First name	Date
Name, address, and phone number of current physician and/or cardiologist
A. CARDIAC HISTORY
Have you had (check all that apply)		Date (mm/yr)
1. Electrocardiogram (EKG)	Normal     Abnormal
2. Exercise treadmill test (ETT)	Normal     Abnormal
3. Nuclear Medicine (thallium test)	Normal     Abnormal
4. Angina or	Normal     Abnormal
4a. Chest pain within the last six months
5. Myocardial Infarction (Heart Attack)
6. Angiogram (Heart catheterization)	Normal     Abnormal
7. Coronary Angioplasty (balloon)
8. Coronary Atherectomy (Plaque Removal)
9. Coronary Stent
10. Coronary Bypass Surgery
11. Congestive Heart Failure (CHF)
12. Valvular Heart Disease, Repair and/or Replacement
13. Stroke (Cerebrovascular Accident)
If you have been hospitalized for any of the above, please indicate the name of the hospital and physician who treated you.
Comments

B. FAMILY MEDICAL HISTORY
Does/did any parent, aunt, uncle (1st generation) or sibling (blood) have a history of the following (check all that apply): Indicate which Family member and age at diagnosis.
1. Heart Attack (Myocardial Infarction)
2. Coronary Bypass Surgery
3. Coronary Angioplasty, Stent, Atherectomy
4. Hypertension (high blood pressure)
5. High Cholesterol or Blood Lipids
6. Cancer
7. Diabetes

C. MEDICATIONS
Do you take the following medications, or have you taken them as treatment in the past?(check all that apply):
	Medication	Dosage (mg)	# per day
1. Cholesterol lowering drugs (e.g. Zocor)
2. Aspirin, Advil, Similar drugs (not Tylenol)
3. Blood pressure lowering drugs
4. Blood-thinning drugs (Coumadin)
5. Thyroid medication
6. Immunosuppresive drugs (Prednisone)
7. Any other medications (answer below)
Please list all other current medications. Include any over-the-counter medications, vitamins and supplements (incl. Herbal, body building supplements). Also include dosage and frequency.
D. FOR WOMEN ONLY:   Menopause Status
Pre-menopausal         Menopausal          Post Menopause (age at menopause _____ )
Do you take:	Medication	Dosage (mg)	# per day
1. hormonal medications?
2. estrogen replacement therapy?
3. birth control pills?

E. OTHER MEDICAL CONDITIONS?
Have you ever been treated for disease, condition, or symptom related to the following? (Check all appropriate)
1. Pulmonary (lungs)	____________________________________
2. Arthritic/muscular	____________________________________
3. Endocrine (thyroid, hormonal)	____________________________________
4. Liver	____________________________________
5. Gastrointestinal (colon, stomach)	____________________________________
6. Skin (dermatological)	____________________________________
7. Nervous system (brain)	____________________________________
8. Cancer (neoplasm)	____________________________________
9. Trauma	____________________________________
10. Hematologic (blood disorders)	____________________________________
11. Ophthalmologic (eye)	____________________________________
12. Ear, nose, or throat	____________________________________
13. Kidneys, bladder, reproductive organs	____________________________________
14. Allergies/sensitivities/drug reactions	____________________________________
15. Diabetes	____________________________________
16. High blood pressure	____________________________________
17. High Cholesterol	____________________________________
18. Other	____________________________________

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