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
Menu
Home
About Us
our providers
MEDICAL SERVICES
HOSPITALS AND INSURANCES
Patient Resources
Patient forms
Testing Instructions
PATIENT EDUCATION
Blog
Contact
Medication and
Social Information
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Date
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Patients Name:
DOB:
Referring Physician:
Reason for cardiology visit:
Allergies:
PLEASE LIST CURRENT MEDICATIONS:
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MEDICATION
DOSAGE
FREQUENCY
SOCIAL HISTORY
Do you smoke or use tobacco products?
Yes
No
Former Smoker
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If yes, how many packets per day?
For how many years?
Alcohol:
Daily
Occasionally
Never
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Caffeine:
Daily
Never
If any, how much caffeine intake per day?
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Exercise:
Daily
Occasionally
Never
If any, what type of exercise?
Submit
