Cardiology Patient Intake

OVERALL_INSTRUCTIONS

Chief Complaint

General Health Follow-Up Form

Form Content

Hello, my name is Emma, and I will help you complete the questionnaire portion of your Cardiology Intake Form. The information that you provide will be summarized for your physician and is needed to complete the exam. We estimate this questionnaire will take around 15 minutes to complete, If you must stop, you can return at a later time to finish. If you want me to repeat a question, just say "repeat." Are you ready? Symptom Assessment: Have you experienced any of the following symptoms? (Show Option List) - Shortness of breath - Fatigue or low energy - Swelling in your legs or feet, - Weight gain - Dizziness or lightheadedness, - Chest discomfort or pain (If no, move on. If yes, ask: "Please specify which symptoms and provide details such as severity or circumstances.") Daily Activities and Functional Status: Have you noticed changes in your ability to perform daily tasks? If yes, please specify the tasks that have become more difficult. Weight and Blood Pressure Monitoring: What is your current weight? Is your weight stable? Yes/No (If no, move on. If yes, ask: "How much has it changed and over what period?") Do you check your blood pressure? If yes, can you provide your recent readings for morning, afternoon, and/ or evening? Medications and Side Effects: Are you taking any prescription medications currently? Can you provide the name and dosage of the medications? Are you experiencing any side effects from your medications? If yes, can describe these side effects? Diet and Fluid Intake: Are you on a low-sodium diet? What is your average daily fluid intake? Other Health Concerns: Do you have any new or worsening health issues or symptoms? Please upload any relevant medical reports or images you would like the doctor to review. End. (Show the following information when questionnaire complete) Thank you for completing the questionnaire. We’ll share this information with your healthcare provider.