New Consult and Follow Up

1. New Patient Registration Form

• Personal Information: Name, date of birth, address, phone number, email.
• Insurance Details: Provider name, policy number, group number.
• Emergency Contact: Name, relationship, phone number.
• Primary Care Physician: Name, contact information.

2. Medical History Form

• Current Medical Conditions: High blood pressure, diabetes, heart disease, etc.
• Past Medical History: Surgeries, hospitalizations, and chronic illnesses
• Family History: History of heart disease, stroke, or other cardiovascular conditions.
• Medications: Current prescriptions, over-the-counter drugs, and supplements.
• Allergies: Medications, food, or environmental allergies.

3. Lifestyle and Risk Factors Questionnaire

• Smoking and Alcohol Use: Current or past habits and frequency.
• Dietary Habits: Typical meals, restrictions, and preferences.
• Exercise Routine: Frequency, type, and duration of physical activity.
• Stress Levels: Sources of stress and coping mechanisms.

4. Symptoms Checklist

• Chest pain, shortness of breath, palpitations, dizziness, fatigue, swelling, etc.
• Frequency, duration, and triggers of symptoms.

5. Consent Forms

• HIPAA Authorization: Patient consent to share medical information.
• Treatment Consent: Authorization for diagnostic tests, treatments, or procedures.
• Financial Agreement: Responsibility for payments not covered by insurance.

6. Referral Information

• Reason for Visit: Referred by a physician or self-referred.
• Previous Tests/Reports: Electrocardiograms, stress tests, lab results, etc.

7. Patient Expectations and Goals

• Questions about what the patient hopes to achieve with cardiology care (e.g., symptom
  relief, prevention of heart disease, etc.).