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Home
Services
- Diagnostic Testing Services
About
Locations
- Dallas
Contact Us
Patient Forms

New Patient Health Questionnaire

0323 - New Patient Health Questionnaire

Please note that our average time per patient in the first visit is 2-3 hours.

Step 1 of 15

6%

Please do note that our average time for a new patient appointment is 2-3 hours.
Date:*
Patient Name:*
BIRTHDATE
Month
Day
Year
Age:
Gender:*
- Male
- Female
Primary Care Physician:*
How did you find us?
- Referring Physician
- Friend
- Internet
1. Please INDICATE all the reasons for your visit (Check all that apply)
- Chest Pain
- Shortness of Breath
- Palpitations
- Dizziness/Fainting
- Blurry Vision
- Hypertension
- Hypotension
- High Cholesterol
- Heart Failure
- Coronary Artery Disease
- Swollen Extremities
- Postural Orthostatic Tachycardia Syndrome
- Pacemaker/Defibrillator Evaluations
- Arrhythmia Evaluation
- Possible Testing
- Pre Surgical Evaluation
- Establish New Cardiologist

2. Have you had any heart disease and/or prior testing?
Do you have a Heart Murmur/Valve Prolapse?
- Yes
- No
Have you ever had Rheumatic/Scarlet Fever?
- Yes
- No
Have you ever had a Heart Attack?
- Yes
- No
Have you ever had a Heart Cath/Angioplasty/Stent?
- Yes
- No
If yes, what year?
Have you ever had Bypass Surgery?
- Yes
- No
If yes, what year?
Do you have an implantable pacemaker/defibrillator?
- Yes
- No
Which Manufacture?
If yes, what year?
Do you have an implantable loop recorder?
- Yes
- No
Which Manufacture?
If yes, what year?
Have you ever had a Stress Test?
- Yes
- No
If yes, what year?
Have you ever had an Echocardiogram?
- Yes
- No
If yes, what year?
Have you ever had a Carotid Doppler?
- Yes
- No
If yes, what year?
Have you ever had a Holter Monitor (24 Heart Monitor)?
- Yes
- No
If yes, what year?

3. Which of these risk factors for heart disease do you have?
Have you ever had High Cholesterol?
- Yes
- No
Have you ever had High Blood Pressure?
- Yes
- No
What does your blood pressure usually run?
Are you a Diabetic?
- Yes
- No
If yes, what was you last HgA1C?
If you are a female, do you have Female Menopause?
- Yes
- No
Are you a Current or Recent Smoker?
- Yes
- No
If you have quit, what year?
Have you are taking Phen or Fen Weight Loss Medication?
- Yes
- No

4. Do you have any blood vessels diseases?
Do you have Carotid Disease or Endarterectomy?
- Yes
- No
When?
Have you ever had a Stroke or TIA (Mini-Stroke)?
- Yes
- No
When?
Do you have an Aortic Aneurysm?
- Yes
- No
When?
Do you have Poor Leg Circulation?
- Yes
- No
Do you have any Venous Thrombosis (Leg Clots)?
- Yes
- No
When?
Do you have any Pulmonary Embolism (Lung Clots)?
- Yes
- No
When?

5. Do you have dizziness/lightheadedness/syncope (passing out)?
Have you ever had a fainting or black out spell?
- Yes
- No
If yes, describe in your own words each spell or last three spells.
1st Spell
2nd Spell
3rd Spell
Were any of the above spells accompanied by (Check all that apply)
- Nausea/Vomiting
- Blurry Vision
- Chest Pain
- Fast/Irregular Heart Beat
- Shortness of Breath
- Head Ache/Pounding
- Did they occur in a standing a position?
- Did they occur in a sitting position?
- Do you get Dizziness/Lightheaded when you stand up suddenly?

6. Do you have palpitations?
Do you ever have Palpitations (awareness of heart beat)?
- Yes
- No
If yes, how would you classify your palpitations? (Check all that apply)
- Fast Heart Beat
- Irregular Heart Beat
- Normal Beats with Skipped or Extra Beats
- Unknown
- Other
What do you think makes your palpitations worsen? (Check all that apply)
- Stress
- Exercise
- Sleep
- After Eating
- Other

7. What is your Past Surgical History(Operations)?
(Do not re-list any cardiac operations already listed)
Example - Procedure: Appendectomy
Year: 1995
Location: Medical City of Dallas
Procedure:
Year:
Location:
Procedure:
Year:
Location:
Procedure:
Year
Location:
Procedure:
Year:
Location:
Procedure:
Year:
Location:
Procedure:
Year:
Location:

8. What are your current Medications?
(Please list all your prescription medications, non-prescription medications, vitamins, and over the counter medication including aspirin.)
NAME I DOSAGE/STRENGTH | FREQUENCY
Example - Lasix I 40 mg I 2 tabs am / 1 tab pm
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________
__________________________________________ | __________________________________________ | __________________________________________ / __________________________________________

9: Are you allergic to any medication?
- Yes
- No
(If no, skip to the next section)
Please list all medications to which you have an allergy to or adverse response to and list the reaction.
MEDICATION I REACTION
Example - Penicillin I Arm Rash
1.
2.
3.
4.
5.

10. What is your medical history?
1. Have you ever had Hepatitis/Jaundice?
- Yes
- No
If yes, what year?
2. Do you have Asthma?
- Yes
- No
If yes, what year?
3. Have you ever had a Peptic Ulcer?
- Yes
- No
If yes, what year?

11. What is your social history?
Marital Status:
Occupation:
Hours a week you work?
Do you exercise?
- Yes
- No
How many hours per week?
Types of activity:
Do you ever drink alcohol?
- Yes
- No
Drinks per week?
Quit Year:
Do you smoke?
- Yes
- No
Quantity:
Quit Year:
Do you do illicit drugs:
- Yes
- No
Do you consume caffeine?
- Yes
- No
How much?

12. What is your family history?
(Please fill out details of your biological relatives only)
Father
Illness
Living
- Yes
- No
Age
Mother
Illness
Living
- Yes
- No
Age
Brother(s)
Illness
Living
- Yes
- No
Age
Sister(s)
Illness
Living
- Yes
- No
Age
Son(s)
Illness
Living
- Yes
- No
Age
Daughter(s)
Illness
Living
- Yes
- No
Age
Have any of your family members had a history of Heart attack, Angina, Coronary Bypass or Angioplasty under age 55-65?
- Yes
- No
Have any of your family members had a history of Stroke, under age 55 - 65?
- Yes
- No
Do you have any family history of Sudden Cardiac Arrest (Death)?
- Yes
- No

13. Recent Hospitalizations
Have you recently been hospitalized?
- Yes
- No
When?
Where?
If yes, Why?

14. Autonomic Nervous System Questionnaire
(The Autonomic Nervous System plays an important role in many arrhythmias and related symptoms to help us diagnosis your symptoms)
Use the scale below to complete the list regarding your symptoms and their frequencies
- O = Never
- 1 = 1 time a month
- 2 = 2-4 times a month
- 3 = 5-7 times a month
- 4 - Daily
Fainting (Syncope)
- 0
- 1
- 2
- 3
- 4
Dizziness/Lightheadedness (Faintness)
- 0
- 1
- 2
- 3
- 4
Lightheadedness on standing
- 0
- 1
- 2
- 3
- 4
Impaired memory on standing
- 0
- 1
- 2
- 3
- 4
Impaired Memory/Confused
- 0
- 1
- 2
- 3
- 4
Sensation of Head/Room Spinning
- 0
- 1
- 2
- 3
- 4
Head Ache/Head Pounding
- 0
- 1
- 2
- 3
- 4
Tremulousness
- 0
- 1
- 2
- 3
- 4
Exertional Shortness of Breath
- 0
- 1
- 2
- 3
- 4
Shortness of Breath when lying down
- 0
- 1
- 2
- 3
- 4
Sensation of Rapid Heart Beat
- 0
- 1
- 2
- 3
- 4
Sensation of forceful, Slow Heart Beat
- 0
- 1
- 2
- 3
- 4
Chest Discomfort
- 0
- 1
- 2
- 3
- 4
Excessive Sweating during day
- 0
- 1
- 2
- 3
- 4
Excessive Sweating at night
- 0
- 1
- 2
- 3
- 4
Clamminess of Skin
- 0
- 1
- 2
- 3
- 4
Itching of Hands/Feet
- 0
- 1
- 2
- 3
- 4
Trouble tolerating cold
- 0
- 1
- 2
- 3
- 4
Trouble tolerating heat
- 0
- 1
- 2
- 3
- 4
Bloating After Meals
- 0
- 1
- 2
- 3
- 4
Nausea/Vomiting
- 0
- 1
- 2
- 3
- 4
Right Upper Abdominal Pain
- 0
- 1
- 2
- 3
- 4
Difficultly swallowing or choking
- 0
- 1
- 2
- 3
- 4
Saliva dribbling out of mouth
- 0
- 1
- 2
- 3
- 4
Has food ever been stuck in your throat
- 0
- 1
- 2
- 3
- 4
Abdominal discomfort
- 0
- 1
- 2
- 3
- 4
Constipation
- 0
- 1
- 2
- 3
- 4
Heartburn
- 0
- 1
- 2
- 3
- 4
Neck/Shoulder Aches
- 0
- 1
- 2
- 3
- 4
Muscle Aches
- 0
- 1
- 2
- 3
- 4
Joint Aches
- 0
- 1
- 2
- 3
- 4
Pain in legs
- 0
- 1
- 2
- 3
- 4
Leg cramps
- 0
- 1
- 2
- 3
- 4
Blurry vision on standing
- 0
- 1
- 2
- 3
- 4
Blurry/Dimming of Vision
- 0
- 1
- 2
- 3
- 4
Eyes sensitive to light
- 0
- 1
- 2
- 3
- 4
Fatigue/Feeling Weak
- 0
- 1
- 2
- 3
- 4
Trouble falling asleep
- 0
- 1
- 2
- 3
- 4
Difficulty maintaining sleep
- 0
- 1
- 2
- 3
- 4
Daytime fatigue
- 0
- 1
- 2
- 3
- 4
Anxiety
- 0
- 1
- 2
- 3
- 4
Urinary Incontinence/Leaking
- 0
- 1
- 2
- 3
- 4
Difficulty Emptying Bladder
- 0
- 1
- 2
- 3
- 4
Loose/Watery Stools
- 0
- 1
- 2
- 3
- 4

15. Review of Systems:
(Check all that apply)
Cancer (List Any)
Endocrine:
- Low Thyroid
- High Thyroid
- Diabetes
Eyes:
- Glaucoma
- Cataracts
Lungs/Breathing:
- Persistent Cough
- Bronchitis
- Emphysema
- COPD
- Pneumonia
Neurological:
- Seizures/Epilepsy
- Stroke
Abdomen:
- Hiatus Hernia
Kidney/Bladder:
- Renal Failure
- Dialysis
- Kidney Stones
Infections:
- AIDS
- HIV
Blood:
- Bleeding Problems
- Leukemia

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At The POTS.net, your health is of prime importance. We believe in the philosophy of taking care of patients irrespective of insurance issues.

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Disclaimer: The information provided here is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. While we strive to ensure accuracy, the content may not always reflect the latest medical developments. Always consult a qualified healthcare provider for any medical concerns or before making health-related decisions. The Heartbeat Clinic is not liable for any actions taken based on the information provided here. For any changes to the content or recommendations, please email us at Info@pots.net.

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