About Us
|
Contact Us
Home
Physicians
Services
Patients
Referring MDs
Research
CT Courses
Contact Us
Patients
» Forms » Cardiolite Questionaire
Untitled Document
Cardiovascular Medical Group of Southern California Cardiolite Questionnaire
Date
Patient Name:
Last:
First:
Sex:
Male
Female
Date of Birth:
Height:
ft.
in.
Weight:
lbs.
Please answer the following questions. You may circle YES or NO or fill in the blanks
1. Have you ever had a stress test?
No
Yes
If yes, when?
+ve -ve
2. Have you ever had a heart attack?
No
Yes
If yes, when?
3. Have you ever had an angiogram or angioplasty?
No
Yes
If yes, when?
4. Have you ever had heart surgery?
No
Yes
If yes, when?
5. Have you ever had heart bypass surgery?
No
Yes
If yes, when?
6. Have you ever had breast surgery?
No
Yes
If yes, do you have an implant?
No
Yes
7. Have you ever smoked?
No
Yes
If yes, how many years and how much?
8. Have you experienced any chest pain recently?
No
Yes
If yes, when?
How long did it last?
Where in the chest did you feel the pain?
Center
Right
Left
Was the pain related to exercise or stress?
No
Yes
9. Have you ever taken Nitroglycerine?
No
Yes
10. Are there any family members with heart disease?
No
Yes
If yes, who?
11. Have you ever been told by a physician that you have high blood pressure?
No
Yes
If yes, what medication(s) do you take?
12. Have you ever been told by a physician that you have diabetes?
No
Yes
If yes, what medication(s) do you take?
13. Have you ever been told by a physician that you have high cholesterol?
No
Yes
If yes, what medication(s) do you take?
14. Have you ever been told by a physician that you have asthma, emphysema or COPD?
No
Yes
If yes, what medication(s) do you take?
15. Are you allergic to any food or medication?
No
Yes
If yes, what?
16. Have you had any other imaging procedure during the last three days?
No
Yes
If yes, what?
17. Can you walk fast and non-stop for six minutes or more?
No
Yes
If not, why?
18. Other then mentioned above, what medications are you currently taking?
Patient Signature:
