New Consult Intake Questions New Consult Intake Questions Patient Name(Required) First Last Health Card Number With Version CodeDate of Birth MM slash DD slash YYYY Please enter your most recent blood pressure reading if you have a home blood pressure machineHeight(Required)Weight(Required)Family Doctor Name(Required)Family Doctor Telephone(Required)Have you in the past year experienced the below? (select all that apply) Chest Pain Palpitations (feeling fast heart beats) Shortness of breath (either when walking up a flight of stairs, or walking 3 blocks on level ground) Dizziness Fainting Spells Have you had any previous operations or surgeries?(Required) Yes No Type of operation/surgery and approximate date(s):(Required)Have you ever had a heart attack?(Required) Yes No When did you experience the heart attack?(Required)Have you ever had a stroke?(Required) Yes No When did the stroke occur?(Required)Have you ever been diagnosed with heart failure?(Required) Yes No When were you diagnosed with heart failure?(Required)Have you had a heart stent placed?(Required) Yes No When was the heart stent placed?(Required)Have you had heart surgery?(Required) Yes No When was your heart surgery performed?(Required)Do you have any other medical conditions we should be aware of?(Required) Yes No Please list any chronic illnesses or significant diagnoses(Required)Have you been hospitalized in the last year for any reason?(Required) Yes No Please provide the name of the hospital and the reason for admission(Required)Do you have diabetes?(Required) Yes No Are you currently taking any medications to manage it?(Required) Yes No What medications are you currently taking for diabetes?(Required)Are you a smoker?(Required) Yes No I smoked, but I quit How long ago did you quit?(Required)What age did you start smoking?(Required)How many packs per day do you smoke?(Required)Do you snore when you sleep?(Required) Yes No Do you have sleep apnea?(Required) Yes No Do you use a CPAP?(Required) Yes No Have you been diagnosed with high blood pressure?(Required) Yes No Do you take medications to manage your blood pressure?(Required) Yes No Please list the medications you take to manage your blood pressure(Required)Does anyone in your family have a history of heart disease, heart conditions, or heart surgeries?(Required) Yes No Who in your family had the heart condition or surgery?(Required)What specific heart condition or problem did they have?(Required)How old were they when the condition began?(Required)What is your marital status?(Required) Married Single Divorced Widowed Do you have children?(Required) Yes No How many children?(Required) 1 2 3 4 5 6 7 8 What is your occupation (if you are retired, what was your previous work)?(Required)Do you currently drink alcohol?(Required) Yes No What type(s) of alcohol do you usually consume? (e.g., beer, wine, spirits)(Required)How much do you typically drink at one time?(Required)How often do you drink alcohol?(Required)Please list all medications you are currently taking, including the name, dosage, and how often you take each one.(Required)Please list any allergies you have. If you have no allergies, then write "NKDA"(Required)Please indicate which vaccinations you have received by checking all that apply. Flu Shot Shingles Shot Pneumonics Shot Covid Shots Do you see other doctors/specialists?(Required) Yes No Please list their names and their telephone numbers below(Required)
