Atlanta Heart Specialists, Atlanta, GA Atlanta Heart Specialists - Phone Numbers
HOME PHYSICIANS
LOCATIONS
Information
RESEARCH

Patient Follow Up Form

Please fill out the following form. If you would like to download and print this form you may do so by clicking here and saving the page.

Name DOB
Phone # Email
When was your last visit here? Family Dr
Any hospitalizations, surgery or other major illness since last visit?
1.
2.
3.
Any recent heart tests? Echo(cardiac ultrasound) Stress test Nuclear stress test Heart Cath
Other:
Current medications list
Current allergy list
Do you have any specific questions for the doctor on this visit?

Please indicate below. Are you currently experiencing any of these symptoms:

General, constitutional
Good general health lately...................no yes
Recent weight change.........................no yes
Fever/chills............................................no yes
Fatigue..................................................no yes
Musculoskeletal
Joint pain.............................................no yes
Joint stiffness or swelling...................no yes
Weakness of muscles/joints..............no yes
Muscle pain or cramps.......................no yes
Back pain............................................no yes
Difficulty in walking.............................no yes
Eyes and vision
Eye disease or injury.............................no yes
Wear glasses or contact lenses...........no yes
Blurred or double vision........................no yes
Glaucoma...............................................no yes
Skin and breasts
Rash or itching....................................no yes
Change in skin color...........................no yes
Varicose veins....................................no yes
Breast pain..........................................no yes
Ears, nose, throat
Hearing loss..........................................no yes
Ringing in the ears...............................no yes
Sinus problems....................................no yes
Nose bleeds.........................................no yes
Bleeding gums.....................................no yes
Sore throat or voice change...............no yes
Neurological
Frequent or recurrent headaches.....no yes
Lightheaded or dizzy..........................no yes
Convulsions or tingling sensations....no yes
Tremors................................................no yes
Strokes/TIA..........................................no yes
Head injury...........................................no yes
Genitourinary
Frequent urination................................no yes
Burning or painful urination.................no yes
Blood in urine.......................................no yes
Sexual difficulty....................................no yes
Irregular periods..................................no yes
Psychiatric
Memory loss or confusion..................no yes
Nervousness/anxiety..........................no yes
Depression.........................................no yes
Sleep problems..................................no yes
Snoring................................................no yes
Respiratory
Frequent coughing.............................no yes
Spitting up blood................................no yes
Shortness of breath...........................no yes
Asthma or wheezing..........................no yes
Endocrine
Glandular or hormone problem...........no yes
Thyroid disease....................................no yes
Diabetes................................................no yes
Excessive thirst or urination.................no yes
Heat or cold intolerance.......................no yes
Gastrointestinal
Loss of appetite.................................no yes
Constipation.......................................no yes
Nausea or vomiting...........................no yes
Frequent diarrhea.............................no yes
Blood in stool.....................................no yes
Stomach pain....................................no yes
Hematologic/Lymphatic
Slow to heal after cuts..........................no yes
Easily bruise or bleed..........................no yes
Anemia..................................................no yes
Phlebitis................................................no yes
Transfusion...........................................no yes
Swollen glands.....................................no yes
Any other problems not yet identified?
 
Copyright © 2013. Atlanta Heart Specialists
Atlanta Heart Specialists