ࡱ>  sbjbjVV 4<<% !!!8?!'!Yo-V,Y"YYYZ 1ʣ {V}V}V}V}V}V}V \^}V- ZZ}V YYY   # Y Y{V {V  j_POUY;i!#R2gVY0YMR6_#6_dOU6_ OUư $}V}V Y6_ : LEONARD J. SCUDERI, M.D., F.A.C.C. Diplomate, American Boards of Internal Medicine & Cardiovascular Diseases CardioFit Medical Group, Inc. PREVENTIVE AND INTERVENTIONAL CARDIOLOGY 23441 Madison Street, Skypark Bldg. 8, Suite 215 Torrance, CA 90505 Phone (310) 791-5577 Fax (310) 791-5575 CARDIOVASCULAR HEALTH QUESTIONNAIRE Last name  FORMTEXT      First name  FORMTEXT      M.I. FORMTEXT       Date of birth  FORMTEXT      / FORMTEXT      / FORMTEXT       Age  FORMTEXT       years, Today s date FORMTEXT      / FORMTEXT      / FORMTEXT       Welcome to the cardiology practice of Dr. Leonard J. Scuderi, CardioFit Medical Group, Inc. We look forward to providing you with the finest cardiovascular care available. The following questionnaire will assist us in collecting all relevant medical information in anticipation of your upcoming cardiology consultation with Dr. Scuderi. It will make it possible for Dr. Scuderi to thoroughly evaluate your cardiovascular status, and provide you with a comprehensive, up-to-date, easily explained summary of your cardiac status. Please read the following two bulleted items carefully: This CARDIOVASCULAR HEALTH QUESTIONNAIRE, as well as, accompanying PATIENT DEMOGRAPHIC FORM, PATIENT INSURANCE FORM, AND OFFICE POLICY NOTICE must be completed in their entirety and received by our office at least 24 hours PRIOR TO YOUR APPOINTMENT WITH THE CLINICAL SPECIALIST (the first of your two visits). Please note that a self-addressed envelope is enclosed for your convenience in order for you to meet this deadline. Thank you for your cooperation as we assist you in attaining optimal cardiovascular health. Most of the questions are self-explanatory and merely require a checkmark, yes or no answer, or several-word response. If you have any difficulty completing this form, then please call our office well in advance of your appointment with the Clinical Specialist so that you may obtain clarification of any portion of the questionnaire that you are unable to complete. Note that your appointment with the Clinical Specialist precedes your appointment with the doctor. Thank you in advance for your participation in providing us with this vital information; your time and effort are truly appreciated. CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. Who referred you to Dr. Scuderi (physician, family member, friend)?  FORMTEXT       Please list all physicians with whom you follow-up and to whom you wish to receive a copy of your upcoming cardiology consultation: Specialty Dr. s First name Last name City  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       What is the primary problem for which you have been referred?  FORMTEXT       What questions would you like addressed in order of importance? 1.  FORMTEXT       2.  FORMTEXT      3.  FORMTEXT       4.  FORMTEXT       CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. Current Cardiovascular History Please carefully read the symptom descriptions below. Use a red pen to place a checkmark  " within the brackets below corresponding to any symptoms that you have experienced within the last three months.  FORMCHECKBOX  Discomfort/ache involving your chest, neck, jaw, left shoulder, left arm, or back but never occurs during physical activity (leisure walking, brisk walking, walking up stairs, or jogging)?  FORMCHECKBOX  Discomfort/ache involving your chest, neck, jaw, left shoulder, left arm, or back consistently precipitated by physical activity (leisure walking, brisk walking, walking up stairs, or jogging) and is relieved by rest?  FORMCHECKBOX  Difficulty breathing during physical activity and is relieved by rest?  FORMCHECKBOX  Difficulty breathing while lying down, but does not occur when propping oneself up with more pillows?  FORMCHECKBOX  Awaking in the middle of the night, gasping for air, but not for just a few seconds and not related to nightmares?  FORMCHECKBOX  Ankle swelling?  FORMCHECKBOX  Muscle soreness specifically meeting all of the following? lasting hours on a daily basis, and involving both sides of your body, and lasting at least one week, and not related to trauma, and not simply muscle cramps lasting seconds to minutes CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C.  FORMCHECKBOX  Persistent calf pain not episodic muscle cramps?  FORMCHECKBOX  Fatigue or discomfort involving one or both of your legs upon walking a predictable distance and resolves within a few minutes of stopping?  FORMCHECKBOX  Palpitations, irregular heart beat, or thumping sensation within your chest?  FORMCHECKBOX  Lightheadedness? Not vertigo or a spinning sensation.  FORMCHECKBOX  Severe lightheadedness to the point where you need to hold onto something for fear that if it were to worsen, you might lose consciousness and fall? Not vertigo or a spinning sensation that would cause you to simply stumble and fall while being alert.  FORMCHECKBOX  Passing out, losing consciousness, or fainting?  FORMCHECKBOX  Persistent fatigue, tiredness, or lack of energy?  FORMCHECKBOX  Weakness isolated to one side of your body involving an arm and/or leg?  FORMCHECKBOX  Inability to move one side of your body involving an arm and/or leg?  FORMCHECKBOX  Transient loss of vision involving a particular area of your visual field or as though a black curtain were being pulled over your eyes?  FORMCHECKBOX  Severe headaches of the magnitude that you would consider to be the worst you have ever experienced in your life?  FORMCHECKBOX  Persistent fevers recorded by a thermometer lasting more than one week? CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C.  FORMCHECKBOX  Profuse perspiration occurring at rest?  FORMCHECKBOX  Coughing with or without sputum or phlegm production (specify)?  FORMCHECKBOX  Coughing up blood?  FORMCHECKBOX  Persistently poor appetite?  FORMCHECKBOX  Persistent nausea?  FORMCHECKBOX  Discomfort located in the upper center of your abdomen?  FORMCHECKBOX  Bright red blood from the rectum or red stools, not related to constipation or hemorrhoids?  FORMCHECKBOX  Black, not dark brown, stools?  FORMCHECKBOX  Vomiting blood?  FORMCHECKBOX  Frequent or profuse nosebleeds?  FORMCHECKBOX  Significant, not merely mild, bruising? CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. Past Cardiovascular History Please place a red checkmark  " within the brackets below corresponding to any item that you have been made aware of regarding your past medical history. Do any of the following apply to you? If you are unsure, then place a  question mark within the brackets.  FORMCHECKBOX  Less than ideal blood lipid, cholesterol, or triglyceride profile? If so, since what year?  FORMTEXT      . The  ideal profile would depend upon the presence of coronary artery disease or risk factors for coronary artery disease. The purpose of this question is to determine whether any physician has expressed concern about your profile in the past. If so, then place a checkmark above and enter the year corresponding to when you were first told.  FORMCHECKBOX  Diabetes (elevated blood sugar)? If so, since what year?  FORMTEXT        FORMCHECKBOX  Family history of premature coronary artery disease? Specifically, relatives known to have developed coronary artery disease, heart attack, undergone bypass surgery, or sudden cardiac death at the age of less than 55 years in male relatives or less than 65 years in female relatives?  FORMCHECKBOX  Obesity? For adults, overweight and obesity ranges are determined by using weight and height to calculate a number called the body mass index (BMI). BMI is used because, for most people, it correlates with their amount of body fat. An adult who has a BMI between 25 and 29.9 is considered overweight. An adult who has a BMI of 30 or higher is considered obese. Today, we will provide you with your BMI in order to identify obesity as a potential risk factor for coronary artery disease. If you are obese, then since what year?  FORMTEXT        FORMCHECKBOX  Please check this item if you are committed to losing excess weight. CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. If you would like to know your BMI at any time while at home, you may use the CDC website to calculate the number within seconds. HYPERLINK "http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm"http://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm [ ] Metabolic or insulin resistance syndrome? If so, since what year, have you had three or more of the following criteria that are required to diagnose this disorder?  FORMTEXT       Yes No ?  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Increased abdominal girth: men >40 in., women > 35 in.  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Increased triglycerides blood levels: > 150 mg/dL  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  HDL cholest: < 40 mg/dL (men) < 50 mg/dL (women)  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Fasting blood sugar > 110 mg/dL  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Systolic blood pressure (top number) > 130 mm Hg  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Diastolic blood pressure (bottom number) > 85 mm Hg  FORMCHECKBOX  Elevated lipoprotein (a) blood level?  FORMCHECKBOX  Elevated homocysteine blood level?  FORMCHECKBOX  Elevated cardiac/high-sensitivity C. reactive protein (CRP) blood level?  FORMCHECKBOX  Coronary calcification by Electron Beam CT (EBCT) scanning?  FORMCHECKBOX  Carotid artery disease (arterial blockage involving the neck)? If so, since what year?  FORMTEXT        FORMCHECKBOX  Carotid endarterectomy (surgical removal of carotid artery plaque)? If so, what year?  FORMTEXT        FORMCHECKBOX  Peripheral artery disease (arterial blockages most commonly involving the legs)? If so, since what year?  FORMTEXT        FORMCHECKBOX  Peripheral bypass graft surgery (surgery providing alternative flow to the limbs)? If so, what year?  FORMTEXT       CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C.  FORMCHECKBOX  Transient ischemic attack (TIA). This is characterized by temporary speech difficulty, loss of vision, or loss of function involving a hand or leg on one side of the body lasting less than 24 hours)? If so, what year?  FORMTEXT        FORMCHECKBOX  Stroke (characterized by speech difficulty, loss of vision, or loss of function involving a hand or leg on one side of the body lasting more than 24 hours)? If so, what year?  FORMTEXT        FORMCHECKBOX  Congestive heart failure (shortness of breath caused by fluid in the lungs)? If so, due to either: Yes No ?  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Systolic heart failure (enlarged, weakened heart)?  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Diastolic heart failure (thickened, stiff heart muscle that pumps strongly but does not relax appropriately)? [ ] Coronary artery disease (arterial blockage involving the coronary arteries)? If so, have you experienced or undergone any of the following: Yes No ? If so, what year?  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Heart attack?  FORMTEXT        FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Coronary angioplasty?  FORMTEXT        FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Coronary stenting?  FORMTEXT        FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Coronary artery bypass graft surgery?  FORMTEXT       CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C.  FORMCHECKBOX  Arrhythmia (heart rhythm disorder)? If so, since what year?  FORMTEXT       Please check any of the following terms you may recognize as pertaining to your own past:  FORMCHECKBOX  Atrial premature complexes (APC s, PACs)  FORMCHECKBOX  Atrial fibrillation  FORMCHECKBOX  Atrial flutter  FORMCHECKBOX  Supraventricular tachycardia (SVT)  FORMCHECKBOX  Ventricular premature complexes (VPCs, PVCs)  FORMCHECKBOX  Ventricular tachycardia  FORMCHECKBOX  Heart block  FORMCHECKBOX  Bradycardia (slow heart rate)  FORMCHECKBOX  Pacemaker implantation? If so, refer to your pacemaker card to provide the following information: Year implanted?  FORMTEXT       Brand?  FORMTEXT       [Biotronik, Guidant, Medtronic, St. Jude] Month/year of last generator replacement [ __/200_ ] Month/year of last pacemaker interrogation [ __/200_ ]  FORMCHECKBOX  Sudden cardiac death? (sudden, unexpected death caused by loss of heart function. Most sudden cardiac deaths are caused by arrhythmias? If so, what year?  FORMTEXT        FORMCHECKBOX  Hypertension (elevated blood pressure on three or more occasions in the absence of pain)? If so, since what year?  FORMTEXT       Yes No ?  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Systolic blood pressure (top number) > 130 mm Hg  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Diastolic blood pressure (bottom number) > 85 mm Hg  FORMCHECKBOX  Hypertensive heart disease (thickened heart muscle most commonly due to elevated blood pressure)? If so, since what year?  FORMTEXT       CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C.  FORMCHECKBOX  Hypertrophic cardiomyopathy (thickened, stiff heart muscle not due to an elevated blood pressure, pumps strongly, but does not relax appropriately)? If so, since what year?  FORMTEXT        FORMCHECKBOX  Heart murmur (heart sound documented by a physician after listening with a stethoscope)? If so, since what year?  FORMTEXT        FORMCHECKBOX  Mitral valve prolapse (longer than usual leaflet(s) length resulting in a bowing backward appearance of the mitral valve as seen during echocardiography (ultrasound of the heart). This may be associated with regurgitation (leakage), and may lead to symptoms of episodic palpitations, chest discomfort, and anxiety. If so, since what year?  FORMTEXT        FORMCHECKBOX  Valvular regurgitation or leakage? Which of the four heart valves are involved? If so, since what year?  FORMTEXT        FORMCHECKBOX  aortic  FORMCHECKBOX  mitral  FORMCHECKBOX  tricuspid  FORMCHECKBOX  pulmonic  FORMCHECKBOX  uncertain  FORMCHECKBOX  Valvular stenosis or narrowing? Which of the four heart valves are involved? If so, since what year?  FORMTEXT        FORMCHECKBOX  aortic  FORMCHECKBOX  mitral  FORMCHECKBOX  tricuspid  FORMCHECKBOX  pulmonic  FORMCHECKBOX  uncertain  FORMCHECKBOX  Heart valve surgery? If so, what year?  FORMTEXT       If so, which valve was surgically treated?  FORMCHECKBOX  aortic  FORMCHECKBOX  mitral  FORMCHECKBOX  tricuspid  FORMCHECKBOX  pulmonic  FORMCHECKBOX  uncertain If so, was it repaired, or if replaced, what type of prosthesis used? (check one of following choices)  FORMCHECKBOX  repaired  FORMCHECKBOX  replaced with mechanical (metal) valve  FORMCHECKBOX  replaced with natural (porcine or bovine) valve CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C.  FORMCHECKBOX  Congenital heart disease? If corrected surgically, what year?  FORMCHECKBOX  Bicuspid aortic valve?  FORMTEXT        FORMCHECKBOX  Atrial septal defect?  FORMTEXT        FORMCHECKBOX  Ventricular septal defect?  FORMTEXT        FORMCHECKBOX  Coarctation of aorta?  FORMTEXT        FORMCHECKBOX  Take antibiotic prior to dental cleaning?  FORMCHECKBOX  Pericarditis (inflammation of the lining surrounding the heart)? If so, what year?  FORMTEXT        FORMCHECKBOX  Endocarditis (heart valve infection)? If so, what year?  FORMTEXT        FORMCHECKBOX  Myocarditis (viral infection causing the heart muscle to become enlarged and weakened)? If so, what year?  FORMTEXT        FORMCHECKBOX  Aortic aneurysm? If so, what year?  FORMTEXT        FORMCHECKBOX  Aortic dissection? If so, what year?  FORMTEXT        FORMCHECKBOX  Aortic surgery for aneurysm? If so, [ ] chest or [ ] abdomen If so, what year?  FORMTEXT        FORMCHECKBOX  Pulmonary hypertension (increased pressure within right side of heart)? If so, what year?  FORMTEXT        FORMCHECKBOX  Pulmonary embolism (PE)? This is characterized by sudden difficulty breathing, chest discomfort, and lightheadedness due to blood clots traveling from the lower body to the lung circulation.  FORMCHECKBOX  Deep venous thrombosis (DVT)? This condition most commonly involves a blood clot located within the deep veins of the thigh or calf, and is associated with leg pain and edema. CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C.  FORMCHECKBOX  Asthma? This condition causes episodic coughing, wheezing, and/or difficulty breathing related to air-borne allergens, cold air, or emotional stress.  FORMCHECKBOX  Pneumonia (infection of the lungs requiring a chest radiograph or x-ray to diagnose)? If so, what year?  FORMTEXT        FORMCHECKBOX  Pleurisy (viral inflammation of the lining of the lungs resulting in sharp pains during deep breathing but resolves immediately during breath holding? If so, what year?  FORMTEXT        FORMCHECKBOX  Pneumothorax (puncture of the lung requiring surgical insertion of a chest tube for at least one day in order to allow re-expansion to occur)? If so, what year?  FORMTEXT        FORMCHECKBOX  Peptic ulcer disease? If so, what year?  FORMTEXT        FORMCHECKBOX  Gastrointestinal bleeding? If so, what year?  FORMTEXT        FORMCHECKBOX  Gastroesophageal reflux disorder (GERD) This condition is characterized by chronic heartburn and is exacerbated by obesity, coffee, chocolate, and acidic foods. If so, what year?  FORMTEXT        FORMCHECKBOX  Hiatal hernia? If so, what year?  FORMTEXT        FORMCHECKBOX  Esophagitis (inflammation of the esophagus resulting in chest discomfort)? If so, what year?  FORMTEXT        FORMCHECKBOX  Esophageal spasm? If so, what year?  FORMTEXT        FORMCHECKBOX  Pancreatitis (inflammation of the pancreas resulting from gallstone, alcohol abuse, or severely elevated blood triglyceride level)? If so, what year?  FORMTEXT        FORMCHECKBOX  Cholecystitis (painful gallstones)? If so, what year?  FORMTEXT       If so, have you had your gallbladder removed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If so, what year?  FORMTEXT       CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C.  FORMCHECKBOX  Costochondritis (inflammation of the rib joints)?  FORMCHECKBOX  Musculoskeletal strain (pulled muscle within the last three months)?  FORMCHECKBOX  Fibromyalgia (chronic rheumatologic condition caused by chronic sleep deprivation and is characterized by muscle aches involving multiple areas)? If so, since what year?  FORMTEXT        FORMCHECKBOX  Rib fracture within last six months?  FORMCHECKBOX  Rheumatoid arthritis (RA)?  FORMCHECKBOX  Systemic lupus erythematosis (SLE)?  FORMCHECKBOX  Injury to? Please also indicate what year it occurred.  FORMCHECKBOX  head  FORMTEXT        FORMCHECKBOX  shoulder  FORMTEXT        FORMCHECKBOX  cervical spine  FORMTEXT        FORMCHECKBOX  neck  FORMTEXT        FORMCHECKBOX  arms  FORMTEXT        FORMCHECKBOX  thoracic spine  FORMTEXT        FORMCHECKBOX  chest  FORMTEXT        FORMCHECKBOX  abdomen  FORMTEXT        FORMCHECKBOX  lumbar spine  FORMTEXT        FORMCHECKBOX  back  FORMTEXT        FORMCHECKBOX  legs  FORMTEXT        FORMCHECKBOX  sacral spine  FORMTEXT        FORMCHECKBOX  Radiculopathy (pain, numbness, tingling, or weakness involving your arms or legs caused by a problem with your nerve roots (branches of spinal cord carrying signals to rest of body)?  FORMCHECKBOX  Herpes zoster (Shingles)?  FORMCHECKBOX  Anxiety?  FORMCHECKBOX  Panic attacks? CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C.  FORMCHECKBOX  Cancer? If so, Year diagnosed  FORMTEXT       Location  FORMTEXT       Treatment  FORMTEXT       Currently in remission  FORMCHECKBOX Yes  FORMCHECKBOX No Currently with metastasis  FORMCHECKBOX Yes  FORMCHECKBOX No Oncology appt w/i last year  FORMCHECKBOX Yes  FORMCHECKBOX No  FORMCHECKBOX  Weight gain or weight loss within last year  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, please estimate how much: Gained  FORMTEXT       lbs. over the last  FORMTEXT       months Lost  FORMTEXT       lbs. over the last  FORMTEXT       months If weight loss, has this been because of: Dieting  FORMCHECKBOX Yes  FORMCHECKBOX No Exercising  FORMCHECKBOX Yes  FORMCHECKBOX No Lack of appetite  FORMCHECKBOX Yes  FORMCHECKBOX No 65.  FORMCHECKBOX  Have you ever had a blood transfusion?  FORMCHECKBOX Yes  FORMCHECKBOX No If so, what year were you transfused?  FORMTEXT      . CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. Allergy History If you are allergic to any medications, then please name them below and place an X in the box that describes the specific type of reaction that you experienced with each particular medication. MedicationRashHivesDifficulty breathingPassed outOther1 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      2 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      3 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       If you are allergic to any of the allergens below, then please place an  X in the box that describes the specific type of reaction that you experienced with that particular allergen. 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SCUDERI, M.D., F.A.C.C. Medications It is extremely important that the information you provide is current and accurate since errors in medication dosing are among the leading causes of preventable morbidity and mortality in the medical field. If you are not absolutely certain of the information, then it is your responsibility to call your pharmacist and/or your primary physician to obtain the necessary information being requested below. Guessing is not an option when it comes to your medications. Please list all medications that you are currently taking. If you do not know the name of the medications but have all of the medication bottles available at home, then please bring all medications with you at your upcoming office visit. Please do not omit birth control, diet pills, cold remedies, allergy shots, laxatives, or any over-the-counter medications. For each medication, please use the guidelines below along with the two  example medications (Med1 and Med2) in the mini-table below to assist you in properly completing your own medication table on the next page: Clearly write the name of the medication. Enter the milligram (mg) dosage of each tablet or capsule. Enter the number of tablets or capsules taken each time. Checkmark whether it is a tablet or capsule. Checkmark the frequency daily (once, twice, three, or four times daily). Note: If once daily, then is it taken in AM, PM, or at bedtime? 1. 2. 3.4. 5. 5.Medication namemg of tab or cap# of tabs or caps each timeTab (" )Cap (" )Once daily if so, then " AM or PMAM "PM"Bed Two times daily (" )Three times daily (" )Four times daily (" )1Example Med1101"""2Example Med23252"" CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. Medication Table 1. 2. 3.4. 5. 5.Medication namemg of tab or cap# of tabs or caps each timeTab " Cap " Once daily if so, then " AM, PM or BedAM " PM "Bed "Two times daily (" )Three times daily (" )Four times daily (" )1 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 2 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 4 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 5 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 6 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 7 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 8 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 9 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 10 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 11 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 12 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 13 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 14 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 15 FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. Hospitalization History If you have been hospitalized for any reason, other than childbirth, please complete the following to the best of your abilities: YearHospitalReason FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Social History Birthplace: City  FORMTEXT       State  FORMTEXT       Occupation:  FORMTEXT       (please " if yes)  FORMCHECKBOX  Retired Exposure to:  FORMCHECKBOX  Toxic chemicals (please " if yes)  FORMCHECKBOX  Radioactive materials  FORMCHECKBOX  Asbestos Marital Status:  FORMCHECKBOX  Single (please " if yes)  FORMCHECKBOX  Happily married  FORMCHECKBOX  Overly stressful marriage  FORMCHECKBOX  Divorced  FORMCHECKBOX  Widow/er CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. Tobacco:  FORMCHECKBOX  Never (please " if yes)  FORMCHECKBOX  Past  FORMCHECKBOX  Active If past or active smoker, please quantify your exposure: Average daily exposure:  FORMTEXT       packs per day Total exposure:  FORMTEXT       years Quit how long ago:  FORMTEXT       years ago  FORMCHECKBOX  Current/Past use of chewing tobacco  FORMCHECKBOX  If active smoker, please check this item at the left if you are committed to quitting. Alcohol:  FORMCHECKBOX  Never (please " if yes)  FORMCHECKBOX  Past  FORMCHECKBOX  Active If past or active, please characterize: Type of ethanol drink:  FORMCHECKBOX  wine (please " if yes)  FORMCHECKBOX  beer  FORMCHECKBOX  liquor Weekly amount:  FORMTEXT       glasses (please insert number)  FORMTEXT       bottles/cans  FORMTEXT       drinks Total exposure:  FORMTEXT       years Quit how long ago:  FORMTEXT       years ago  FORMCHECKBOX  If active heavy drinker, please check this item if you are committed to quitting. CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. Exercise:  FORMCHECKBOX  Not currently (please " if yes)  FORMCHECKBOX  Active If active, please characterize: "Type of exerciseMin/sessionSessions/wk FORMCHECKBOX Jogging FORMTEXT       FORMTEXT       FORMCHECKBOX Brisk walking  FORMTEXT       FORMTEXT       FORMCHECKBOX Tennis FORMTEXT       FORMTEXT       FORMCHECKBOX Walk golf course FORMTEXT       FORMTEXT       FORMCHECKBOX Treadmill FORMTEXT       FORMTEXT       FORMCHECKBOX Elliptical FORMTEXT       FORMTEXT       FORMCHECKBOX Stairmaster FORMTEXT       FORMTEXT       FORMCHECKBOX Weight training FORMTEXT       FORMTEXT       FORMCHECKBOX Swimming FORMTEXT       FORMTEXT       Diet: [please " yes or no] Adherence to:Yes No RelationshipLow-fat intake FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Low-sodium intake FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Low-carbohydrate or diabetic-type diet FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Prudent calorie intake FORMCHECKBOX  FORMCHECKBOX  FORMTEXT        FORMCHECKBOX  If you are committed at this time to changing the items above marked  No , then please checkmark the box to the left.  FORMCHECKBOX  Do you consume caffeinated products? _ FORMCHECKBOX _Yes _ FORMCHECKBOX _No Please indicate the amount of each product you consume on a daily basis:  FORMTEXT       cup(s) of coffee.  FORMTEXT       cup(s) of tea (including green tea). Do not include non- caffeinated tea products, such as chamomile. CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C.  FORMTEXT       can(s) of caffeinated soda (Coke, Pepsi, Mountain Dew).  FORMTEXT       ounce(s) of chocolate.  FORMTEXT       over-the counter medications that contain caffeine (Anacin, Excedrine, Midol, NoDoz, Vivarin).  FORMTEXT       Power (energy) drinks (Red bull, Monster, ect.) Family History Have any family members had any of the diseases or illnesses listed below? You may add any other ones in the spaces provided within the table below. Disease/DisorderYes No Relationship FORMTEXT      Obesity FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Diabetes FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      High blood pressure FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Undesirable cholesterol profile FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Heart attacks FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Cardiomyopathy FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Sudden death FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Bleeding disorder FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Blood clots in legs or lungs FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Tuberculosis FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Stroke FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Peripheral vascular disease FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Early unexplained death FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. 2. Please complete the table below with respect to each family member. RelationAgeHealth ProblemsAge of DeathCause of DeathGrandmother FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Grandfather FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Mother FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Father FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Sister(s) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Brother(s) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Daughter(s) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Son(s) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       CV HEALTH QUESTIONNAIRE LEONARD J. SCUDERI, M.D., F.A.C.C. CARDIOVASCULAR DIAGNOSTIC TESTING While you are not expected to be knowledgeable of the tests listed below, any information with which you may provide us may prevent unnecessary duplication of diagnostic testing especially regarding blood tests that may have recently been performed at other offices. If you are uncertain, then simply place a question mark alongside the test. Test performedMisc.Approx how long ago?Where done?PotassiumBlood FORMTEXT       FORMTEXT      GlucoseBlood FORMTEXT       FORMTEXT      Kidney functionBlood FORMTEXT       FORMTEXT      Liver functionBlood FORMTEXT       FORMTEXT      Lipid profileBlood FORMTEXT       FORMTEXT      High-sensitivity CRPBlood FORMTEXT       FORMTEXT      HomocysteineBlood FORMTEXT       FORMTEXT      Thyroid functionBlood FORMTEXT       FORMTEXT      AnemiaBlood FORMTEXT       FORMTEXT      ProtimeBlood FORMTEXT       FORMTEXT      ElectrocardiogramEKG FORMTEXT       FORMTEXT      Chest radiographX-Ray FORMTEXT       FORMTEXT      EchocardiogramUltrasound FORMTEXT       FORMTEXT      Stress echoUltrasound FORMTEXT       FORMTEXT      Exercise testingTreadmill FORMTEXT       FORMTEXT      Carotid ultrasoundUltrasound FORMTEXT       FORMTEXT      Abdominal ultrasoundUltrasound FORMTEXT       FORMTEXT      Heart cath/angiogramCath lab FORMTEXT       FORMTEXT      Coronary angioplastyCath lab FORMTEXT       FORMTEXT      Coronary stentingCath lab FORMTEXT       FORMTEXT       Congratulations. You have completed your cardiovascular health questionnaire. Your efforts are appreciated and will provide Dr. Scuderi with vital information regarding your current health. I have completed the entire cardiovascular health questionnaire to the best of my knowledge. 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