New Patient Intake FormWe appreciate your cooperation in completing this form. Name * First Name Last Name Date of Birth * MM DD YYYY Marital Status Gender Female Male Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Cell/Mobile Phone (###) ### #### Home Phone (###) ### #### Preferred Phone Cell/Mobile Home Person responsible for the bill Relationship to the person responsible for the bill Address of person responsible for the bill Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Name Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation Reason for Visit Symptoms / Chief Complaint Chest Pain Shortness of breath Nausea/Vomiting (with exertion) Palpitations Weakness/Fatigue Difficulty exercising Passing out Other Please explain what symptoms you have and when did they start? What is your biggest health concern? Please list all Medications and Supplements Do you smoke? Yes No Quit Do you drink? Yes No Please check below if any apply Menopause Do you have any children? Was not diagnosed with any severe Health Conditions. Any Miscarriages? Please list below if there is a Family History of Heart Disease or Stroke and at what age were they diagnosed if known. Mother Father Sibling Grandparents Other family member No Family history of heart disease of stroke Family history of Sudden Cardiac Death Aortic Aneurysm Irregular Heartbeat Heart Attack Did you have any medical issues or surgeries in the past? Do you have any allergies to medications or food? Do you suffer from any of the following? High Blood Pressure High Cholesterol Diabetes, High Sugars/Metabolic Syndrome Depression Anxiety Overweight/Obesity Have you had heart issues? What cardiac tests have you had in the past? Do you exercise? Cardio Strength Training Stress Management Diet Style Vegetarian Pescatarian Typical American Mediterranean Keto Other PRECEIVED STRESS SCALE In the last month, how often have you… (Please circle one) Never, Almost Never, Sometimes, Fairly Often, Very Often. Been upset because of something that happened unexpectedly? Strongly Disagree Disagree Neutral Agree Strongly Agree Felt that you were unable to control the important things in your life? Strongly Disagree Disagree Neutral Agree Strongly Agree Thank you!
