Livonia Radiology Group :: Experienced specialized Quality Services to our patients

Livonia Radiology Group
Experienced specialized Quality Services to our patients

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PRE-VISIT FORM

PRE-VISIT FORM

Complete this form and bring it with you to your first doctor's visit.

Patient Information
Patient Name:
Today's Date:
Referring Physician:
Family Physician:
Date of Birth:		Age:
Height:	ft in	Weight:
Gender:	female male
Marital Status:	single married widowed divorced
Number of Children:

Personal Health History
What is the reason for this visit?

Have you ever had a heart problem?	Yes No
If yes, please explain:

Do you have or have you ever had any of the following?
Rheumatic fever	Shortness of breath
Heart murmur	Congestive heart failure
Heart attack	Pain in calf muscles when walking
Chest pain/pressure	Swelling of the ankles
Heart failure	Fainting
Rapid heart beat or irregular pulse	Dizziness
Light-headedness






Have you ever had a reaction to the dye used in certain cardiac x-rays?
	Yes No I have never had this type of x-ray

Do you have any allergies to medication?		Yes No
If yes, which medications:

Do you currently smoke?	Yes No	Pack per day:
		Number of years:

Have you ever smoked?	Yes No	Date stoppped:

Do you have elevated cholesterol?	Yes No	Last checked:

Do you have high blood pressure?	Yes No	How many years:

Do you drink alcoholic beverages?	Yes No	How much each day:

Are you generally stressed?	Yes No



Do you excerise?	Yes No
If yes, what is your excerise routine:

Occupation:



Are you retired?	Yes No Date

Are you disabled?	Yes No Date

If yes, describe your disability:

Describe any surgeries you have had:
Surgery	Year

Please check any other health condition you have or have had in the past:
		Menstrual dysfunction
	Anxiety	Kidney disease
	Emphysema	Breathing problems
	Ulcer
	Anemia
	Arthritis	Asthma
	Stomach or bowel disorder	Allergies/Hay fever
		Gout
	Urinary problem	Thyroid disease
	Rheumatic fever	Diabetes/high blood sugar
	Depression	Migraine headache
	Constipation	Liver disease
	Cancer	Other

Family History
Do you have a history of heart disease in your family?	Yes No
If yes, indicate relation and age problems started?

About this web site

About this web site

This page was last updated on March 25, 2004.

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