Get Ucla Cardiac Arrhythmia Center Outpatient Questionnaire

Filling out the UCLA Cardiac Arrhythmia Center Outpatient Questionnaire is an essential step in your journey toward effective cardiac care. This guide will provide you with clear instructions on completing the questionnaire online to ensure your medical team has the necessary information to create a personalized treatment plan.

Follow the steps to successfully complete the questionnaire online.

1. Press the ‘Get Form’ button to access the questionnaire and open it in your preferred editing software.
2. Begin by filling out the section regarding current medications. Specify the name of each medication along with the dosage and frequency.
3. In the next field, provide details about any anti-arrhythmic medications you have tried or stopped, including the dates if possible.
4. Document any previous procedures such as cardiac ablations or cardioversions, making sure to include the dates of these occurrences.
5. List any known allergies, including reactions to medications or other substances.
6. Navigate to the past medical history section. Provide information about prior surgeries and hospitalizations, detailing dates and reasons for hospitalization.
7. Indicate your responses to the health-related questions by marking 'Yes' or 'No' to each inquiry regarding your current health.
8. Describe your walking capacity in quantifiable terms, such as feet, miles, or city blocks.
9. Fill out the family history section, noting any occurrences of sudden cardiac death or early coronary artery disease among immediate family members.
10. Complete the social history section by providing details about your occupation, marital status, children, and substance use.
11. In the review of systems section, check the box for any recent health issues that apply to you, providing additional details where necessary.
12. Once all sections are complete, save your changes. You may then download, print, or share the filled-out questionnaire as needed.

Take the next step in your care by completing the UCLA Cardiac Arrhythmia Center Outpatient Questionnaire online.