P1251921728UrvEL

1
540 Lincoln Park Blvd, Suite 200
I N I T I A L V I S I T
Kettering, Ohio 45429
[phone] / [phone] (FAX)
Cardiology
Name
Primary MD
Referring MD
Age
DOB
Date
PATIENT TO FILL OUT
WHY ARE YOU HERE TO SEE THE HEART DOCTOR? (Other
than being sent by your doctor. Be specific.)
DO NOT WRITE IN THIS AREA
Check ? if you have ever had any of the following
CARDIOVASCULAR TESTS or PROCEDURES (include year
done)
?Yes, but dont know details.

• Stress Test or Nuclear Scan
• Heart Ultrasound (Echo)
• Carotid (Neck) Ultrasound
• Cardiac MRI or CT

• Holter Monitor
• Electrophysiology Study
• Ablation of rhythm problem
• Pacemaker or Defibrillator

• Heart cath/Angiogram
• Angioplasty (balloon/stent)
• Coronary Bypass Surgery
• Valve Surgery

PAST MEDICAL AND SURGICAL HISTORY
Check ? YES or NO to each condition you have.
Indicate date of surgery.
NO YES Condition ? ? Pneumonia ? ? Asthma ? ?
Tuberculosis ? ? COPD / Emphysema /
Bronchitis ? ? Heartburn or Reflux ? ? Stomach
or Intestinal Ulcer ? ? Intestinal or Gastric
Bleeding ? ? Diverticular Disease ? ? Colon
Polyp ? ? Other Bowel / Intestinal
Problem ? ? Cirrhosis ? ? Other Liver
Problem ? ? Hepatitis or Yellow
Jaundice ? ? Kidney Stone

• Date Surgery Details
• Appendectomy
• Back Surgery
• Eye Surgery
• Gallbladder Removal
• Hernia
• Hysterectomy
• Lung Surgery
• Joint Replacement
• Prostate Surgery
• Thyroid Surgery
• Tonsillectomy
• Tubal Ligation

NO YES Condition ? ? Kidney Failure ? ? Dialysi
s ? ? Other Kidney / Bladder Problem ? ? Arthrit
is ? ? Herniated Disc ? ? Gout ? ? Other Bone
or Joint Problems ? ? Low Thyroid ? ? High
Thyroid ? ? Thyroid Nodule ? ? Blood Clot in
Leg or Lung ? ? Cancer ? ? Neuropathy

• Other Condition or Illness

• Other Surgery

- 1 -
Version 6/19/2006
2
PATIENT TO FILL OUT
Check ? YES to SYMPTOMS experienced IN THE LAST 4
MONTHS. Check ? NO to symptoms not experienced.
REVIEW OF SYSTEMS
Constitutional NO YES Recurring Fever
? ? Excessive Fatigue ? ? Weight
Gain ? ? Weight Loss ? ? Eyes NO YES Cataract
s ? ? Glaucoma ? ? Ears / Nose / Throat /
Mouth NO YES Decreased Hearing ? ? Nosebleeds
? ? Swallowing Problem ? ? Respiratory NO YES
Cough ? ? Cough Blood ? ? Wheezing ? ? Gastroi
ntestinal NO YES Nausea ? ? Abdominal
Pain ? ? Blood In Stool ? ? Black or Tarry
Stools ? ? Constipation ? ? Diarrhea ? ?
Genitourinary NO YES Frequent Urination at
Night ? ? Men NO YES Enlarged
Prostate ? ? Women NO YES Excess Vaginal
Bleeding ? ? Could you be pregnant? ? ? Musculos
keletal NO YES Muscle aches ? ? Chronic Back
Pain ? ? Joint Pain or Swelling ? ? Dermatologic
NO YES Rash ? ? Hair loss ? ? Neurologic NO Y
ES Headaches ? ? Seizures ? ? Psychiatric NO Y
ES Depression ? ? Chronic Anxiety ? ? Claust
rophobia ? ?
Endocrine NO YES Excessive Thirst ? ? Excessiv
e Urination ? ? Hematologic / Lymphatic NO YES P
rolonged Bleeding ? ? Easy Bruising ? ? Allergic
/ Immunologic NO YES Sinus Trouble ? ? Enviro
nmental Allergies ? ?
DO NOT WRITE IN THIS AREA

• All other systems and unmarked items are
  negative.
• Patient was instructed to inform their primary
  care physician of non-cardiac symptoms.

PATIENT TO FILL OUT
- 2 -
3
Name
DOB
Date
CHIEF COMPLAINT

• As indicated by patient on page 1.

HISTORY OF PRESENT ILLNESS
CARDIOVASCULAR HISTORY
Framingham Risk Score
(See dictated note for details.)
Symptom 1 ?Onset Context ?Frequency ?Locatio
n ?Quality ?Severity ?Timing ?Duration ?Assoc
iations ?Aggravating ?Alleviating Symptom
2 ?Onset Context ?Frequency ?Location ?Qual
ity ?Severity ?Timing ?Duration ?Associations
?Aggravating ?Alleviating Chronic Condition
1 Chronic Condition 2 Chronic
Condition 3

• CAD ?MI ?PCI ?CABG
• Heart Failure / Cardiomyopathy EF Cath___
  Echo____ Nuc____ MRI____
• ?Systolic ?Diastolic ?ICM ?DCM ?Valvular
  ?Hypertrophic
• Valvular HDz ?MR ?MS ?AI ?AS ?TR ?MVR
  ?MVRep ?AVR

?ROS, Allerg, Meds, PMHx, PSHx, SocHx, FamHx
Reviewed.
Cardiovascular
Surgical
Non-CV
- 3 -
(Brief lt3 HPI Items. Extended ?4 HPI Items or ?3
Chronic/Inactive Problems.)
Version 6/19/2006
4
P H Y S I C A L E X A M I N A T I O N
Pulse Reg / Irreg Resp Afebrile /
Febrile Temp (F)
Height (in) Weight (lb) BMI (kg/m2) Waist
(in)
Sitting Left _____/_____ HR _____ Right _____/__
___ Lying Left _____/_____ HR _____ Ankle
_____ ABI _____ Right _____/_____ Ankle
_____ ABI _____ Standing L / R _____/_____ HR
_____
Rad L R Fem L R Pop L R DP L
R PT L R
V I T A L S
BP
ABNORMAL FINDINGS
System AB NL Exam Component
System AB NL Exam Component

• CONST Obese (?Mild, ?Mod, ?Sev) ?Acutely ill
  ?Chronically ill ?Frail ?Malnourished
  ?Cachectic ?Older than stated age ?Younger than
  stated age ?Marfanoid
• SKIN ?Pallor ?Bald ?Scar ?Stasis dermatitis
  ?Pretibial hair loss ?Petechia
• HEAD ?Moon face ?Proptosis ?Ptosis ?Arcus
  Senilus ?Scleral Icterus ?Conjunctival Injection
  ?Hearing impaired ?Hearing aides present
  ?Edentulous ?Poor dentition ?Dental work
  ?Dentures present ?Oral Cyanosis ?Arched palate
• NECK ?JVP elevated (____ cm) ?CV Waves
  ?Thyromegaly ?CEA Scar ?Adenopathy
• RESP ?Tachyp ?Crackles ?Wheezing ?Dullness
  ?Friction Rub ??Breath sounds
• CHEST ?Pectus (?Exc ?Carin) ?Gynecomastia ??AP
  Diam ?Stern Scar
• CV ?Tachy ?Brady Abnormal pulse (?Irregularly
  Irregular, ?Regularly Irregular) ?Extrasystoles
  ?Distant heart sounds ?Increased P2 ?Eject
  Click ?S3 ?S4 ?Friction Rub ?RV Lift
  ?Palpable Thrill ?PMI laterally displaced
• Murmur ?HSM ?SEM ?Diast
• ?Carotid bruit (L / R / B) Carotid (?Blunted
  ?Hyperdynamic ?Bifid ?Parvus) ?Canon A-waves
  ?Aorta widened ?Abd bruit ?Fem bruit (L / R/ B)
• Edema (?Trace, ___) ?Varicose veins ?Asymm
  swelling ?Palpable chords
• ??Pulses DP L ____ R ____ PT L ____ R
  ____

CONST ? ? GEN APPEARANCE SKIN ? ? Inspect (Sub
Q) ? ? Palpate (Sub Q) EYES ? ? Conjunctiva /
Lids ? ? Pupils / Irises ? ? Fundi ? ? Vision E
NMT ? ? External Ears / Nose ? ? Lips /
Dentition ? ? Hearing ? ? TMs / EAC ? ? Nasal
Mucosa / Septum ? ? Oropharynx NECK ? ? Neck ?
? Thyroid LYMPH ? ? Cervical ? ? Supraclavicular
? ? Axilla ? ? Groin ? ? Other RESP ? ? RESP
EFFORT ? ? AUSCULTATION ? ? Percussion ? ? Palp
ation of Chest CHEST ? ? Inspection ? ? Palpatio
n
CV ? ? AUSCULTATION ? ? EDEMA / VARICOSE
VN ? ? PALPATION OF HEART ? ? CAROTID
ARTERIES ? ? ABDOMINAL AORTA ? ? FEMORAL
ARTERIES ? ? PEDAL PULSES ABD ? ? PALPATION ? ?
LIVER / SPLEEN ? ? Hernias Absent ? ? Rectum /
Perineum ? ? Stool Heme MSK ? ? Gait /
Station ? ? Stability ? ? Digits /
Nails ? ? Joints / Bones / Muscles ? ? Muscle
Tone / Strength ? ? Inspect / Palpate ? ? ROM PS
YCH ? ? ORIENTATION ? ? MOOD /
AFFECT ? ? Judgment / Insight ? ? Memory NER ?
? DTRs ? ? Cranial Nerves ? ? Sensation

• Data Points
• 1-Labs reviewed
• 2-EKG/CXR Indep Review
• 1-Diagnostic Studies, Ordered only
• 2-Diagnostic Studies, Indep Review
• Labs
• EKG / CXR
• Review/Order 1 point
• Independent Review 2 points
• Studies
• Review or ordered 1 point
• Indep reciew 2 points
• Delete Counseling no points
• Remove medical decision making
• Additional Data
• Discuss of test result with interpreting MD 1
  point
• Assessment
• Diagnosis points

OTHER ABNL FINDINGS
?Abnormalities Dictated
Exam LOS PF (1-5 items) EPF (? 6 items) D (
? 12 items) C (2 of 9 or All Uppercase/Shaded
and 1 Each Unshaded)
3 Pt - New Problem (no addtl w/u, max 1) 4 Pt -
New Problem (addtl w/u)