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Welcome to Southeastern Cardiology!
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Southeastern Cardiology New Patient Demographics
Patient's Full Name
Date of Birth
-
Month
-
Day
Year
Date
Gender:
Male
Female
Social Security Number:
Enter in XXX-XX-XXXX format
Marital Status
Married
Single
Widowed
Divorced
Preferred Language
Ethnicity:
Hispanic
N/A
Race:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Employer/Occupation:
Email
example@example.com
Web-Enable?
Yes
No
HIPAA Approved Contacts (Emergency Contacts)
Name:
Relationship:
Phone Number:
Please enter a valid phone number.
Referring Doctor:
City/State:
Phone Number:
Please enter a valid phone number.
Primary Care Doctor:
City/State:
Phone Number:
Please enter a valid phone number.
Insurance Information
Please present your insurance card and picture ID when you check in for your appointment
Primary Insurance:
Policy #:
Group#:
Secondary Insurance:
Policy #:
Group #:
If your insurance is through your spouse please provide the information requested below.
Spouse's Name:
Spouse's Date of Birth
-
Month
-
Day
Year
Date
Spouse's Social Security Number:
Enter in XXX-XX-XXXX format
Signature
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Today's Date
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Month
-
Day
Year
Date
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Southeastern Cardiology New Patient Health History
Patient's Full Name
Today's Date
-
Month
-
Day
Year
Date
Date of Birth
-
Month
-
Day
Year
Date
Gender:
Male
Female
Signature
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Symptoms
Please choose Yes or No for each symptom and give complete answers to follow up questions.
Have you experienced any chest pain/pressure/discomfort?
Yes
No
If yes, would you describe your chest pain as mild, moderate, or severe?
If yes, when did the chest pain first occur? Days ago, weeks ago, or months ago?
If yes, how would you describe your chest pain? (pressure, dull, aching, sharp, etc.)
If yes, where is the pain typically located? (i.e. left chest, middle chest, left arm, jaw, etc.)
If yes, does the pain spread anywhere? (i.e. left chest, middle chest, left arm, jaw, etc.)
If yes, does anything bring on the pain or make it worse?
If yes, does anything make the pain better?
Have you experienced any shortness of breath?
Yes
No
If yes, has the shortness of breath gotten better, worse, or stayed the same?
If yes, would you describe the shortness of breath as mild, moderate, or severe?
If yes, when did you first feel short of breath? Days ago, weeks ago, or months ago?
If yes, does the shortness of breath occur with exertion, does not happen with exertion, or happens any time?
Have you experienced any palpitations (fluttering, pounding heart beat, racing or fast heart beats)?
Yes
No
If yes, how would you describe the palpitations? (i.e. fluttering, pounding, racing, etc.)
If yes, how often do you feel the palpitations? every day, most days, occasionally, or rarely?
If yes, when did the palpitations begin? Days ago, weeks ago, or months ago, or years ago?
If yes, do you take any medications for palpitations? Please list the specific medication(s).
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Medications and Pharmacy
Which local pharmacy do you use? Please list the name and address.
Do you use a mail order pharmacy? If yes, which one?
Please list all medications you are CURRENTLY taking, to include prescriptions, over the counter medicines, and vitamins/supplements.
Medication
Dose
How many times a day?
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
If you have additional medications to list, please enter them below.
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Past Medical History
Medical History
No past medical problems
Coronary artery disease (i.e. blockages in your heart, cardiac stents, or open heart bypass surgery)
Myocardial infarction (heart attack)
Congestive heart failure (CHF)
Aneurysm- as in AAA or aortic aneurysm
Aneurysm- as in brain aneurysm
Atrial Fibrillation, or a-fib
Peripheral Vascular Disease (i.e. stents in your legs or arms, or bypass surgery on your legs/groin)
Heart Murmur
Heart Valve issues, disease or replacement
Hypertension, i.e. high blood pressure
Hypercholesterolemia or Hyperlipidemia (high cholesterol)
Hypothyroidism
Hyperthyroidism
Diabetes
Kidney Disease
Cancer
Asthma
Bleeding Disorder
Blood Clots
Pulmonary Embolism, i.e. blood clot in the lungs
Stroke or TIA
GERD (reflux)
Hiatal Hernia
COPD
Seizure disorder
Sleep Apnea
Other
If yes to cancer, please specify which type
Please list all food and medication allergies below
Allergen
Reaction
Allergy
Allergy
Allergy
Allergy
Allergy
Please list any additional allergies below.
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Please list all surgeries and procedures below
Surgery
Date
Surgeon/Doctor
Surgery/Procedure
Surgery/Procedure
Surgery/Procedure
Surgery/Procedure
Surgery/Procedure
Surgery/Procedure
Please list any additional surgeries or procedures below
Please list any recent hospitalizations and the reason
Hospital Name/Location
Reason
Date(s)
Hospitalization
Hospitalization
Hospitalization
Please list any additional RECENT Hospitalizations below
Family Medical History
Yes
Family Member
Age Diagnosed
Alcoholism
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Aneurysm
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Asthma
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Blood Clotting Disorder
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Coronary Artery Disease
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Cancer
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
COPD
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Diabetes
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Heart Valve Issues
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
High Cholesterol
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
High Blood Pressure
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Hyperthyroidism
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Hypothyroidism
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Kidney Disease
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Myocardial Infarction
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Sleep Apnea
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Stroke/TIA
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
Other
Father
Mother
Sister/Brother
Grandfather
Grandmother
Child
If you selected Cancer, please specify which type
If you selected Other, please specify which disease/diagnosis
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Smoking History
Never Smoked
Former Smoker
Occasional Smoker
Current, every day Smoker
If you are an occasional or every day smoker, please indicate how many cigarettes per day
If you use a different nicotine or tobacco product, aside from cigarettes, please indicate the type and frequency below
Have you had a drink containing alcohol in the last year? (Yes or No)
If yes, how often did you have a drink containing alcohol in the last year?
Never
Monthly
2-4 times per month
2-3 times per week
4 or more times per week
If yes, how many drinks did you have on a typical day when you were drinking, in the past year?
1 or 2 drinks
3 or 4 drinks
5 or 6 drinks
7 to 9 drinks
10 or more drinks
If yes, how often did you have 6 or more drinks in a single day, in the past year?
Never
Less than monthly
Monthly
Weekly
Daily or almost Daily
Have you ever used illicit drugs? (Yes or No)
If yes, please indicate which type, when you started, and how often you used the drug.
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Southeastern Cardiology Alternative Communication Form
Please review the document below before completing this form
I authorize Southeastern Cardiology Associates, in regards to my protected health information:
To speak with anyone listed on the Right to Share information list, and give my prescriptions to them as indicated below
To speak only with me
Right to Share Information with Family and Friends
Name
Yes, can pick-up prescriptions
No, cannot pick-up prescriptions
Name
Name
Name
Name
Patient's Name
Patient's Date of Birth
-
Month
-
Day
Year
Date
Patient's Signature
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Today's Date
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Month
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Day
Year
Date
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Southeastern Cardiology Consent to Routine Procedures and Treatments
Please review the consent document below before signing.
Patient's Signature
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Today's date
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Month
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Day
Year
Date
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Southeastern Cardiology New Patient Financial Policy
Please review the financial policy below before signing this form.
Patient's Name
Patient's Signature
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Today's Date
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Month
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Day
Year
Date
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Southeastern Cardiology New Patient Records Release
Please review the Records Release below before signing this form.
Patient's Name
Patient's Date of Birth
-
Month
-
Day
Year
Date
Last 4 digits of Patient's Social Security Number
Patient's Signature
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Southeastern Cardiology New Patient HIPAA Acknowledgement
Please review the HIPAA Acknowledgement below before signing this form.
Patient's Signature
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Today's date
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Month
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Day
Year
Date
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Southeastern Cardiology Testing Cancellation Policy
Please review the document below before signing this form
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