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Get Cardiology Patient Intake Form

T Illness (Why are you here today?): Past Cardiovascular History Disease/Condition Yes Angina Chest Pain Heart Murmur Palpitations Supraventricular Tachycardia (SVT) Atrial Fibrillation Arrhythmia: Type? Loss of Consciousness Heart Attack Heart Disease: Type? Heart Failure: Type? Coronary Artery Disease Peripheral Vascular Disease (PVD) Lipid/ Cholesterol Disorder Type? High Blood Pressure Aneurysm: Type? Edema Stroke/TIA Sleep Apnea No Yes Yes Yes Yes Yes No Yes Yes Yes No No No Yes No.

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