Bay Area Heart

Important! Call 911 if you are experiencing any symptoms of a heart attack.

(832) 905-5940

infobah@qoroshealth.com

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Important! Call 911 if you are experiencing any symptoms of a heart attack.

Surgical Center
Patient Portal
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MEDICAL HISTORY

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Family History

If any of your Families members listed suffer from Medical History, please fill bubble as appropriate.

Father:
Mother:
Siblings:

Please fill in all bubbles regarding medical history, surgical history, and hospitalizations as necessary. If not listed, please write them in space provided.

Past Medical History

Anemia
Anxiety
Enlarged Heart
Deep Vein Thrombosis
Elevated Cholesterol
High Blood Pressure
Kidney Disease
Asthma
Cardiac Arrhythmia
Congestive Heart Failure
Depression
Heart Disease
Hyperthyroidism
Stroke
Chest Pain
Cardiac Murmur
Chronic Cough
Diabetes
Heartburn
Hypothyroidism

Surgical History

Appendix Removed
Gall Bladder Removed
Hysterectomy
Back Surgery
Bowel Surgery
Open Heart Bypass
Pacemaker
Cataract Removal
Hernia Repair
Tonsils Removed

Hospitalization

Heart Attack
Chest Pain
Anemia
Congestive Heart Failure
Atrial Fibrillation
Shortness Of Breath
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