Hello!
Welcome to the SDACC Lipid Clinic, I am looking forward to our upcoming visit! I ask that you please take the time to fill out the questionnaire below. It could take you up to 20 minutes to complete, though I believe it will be a worthwhile investment of your time. Filling this out accurately and completely will help us more quickly zero in on the important issues during our appointment and will help focus our discussion. This will make our time together much more productive.
So, I thank you in advance for taking the time to complete the form, and I look forward to seeing you soon. Please do not hesitate to reach out to us if you have any questions before your visit.
Sincerely,
Richard Saxen MD
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Patient History |
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First Name |
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Last Name |
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Phone Number |
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Date of Birth |
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Please describe the health concerns that bring you to our clinic. |
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Please tell us about your main goal(s) for our visit. |
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Were you referred by a medical provider? If so, who? |
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Please list any current or past significant medical conditions. Ex: hypertension, diabetes, pneumonia, car accident, fractures, etc. |
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Please list all past surgeries and approximate dates. |
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Current Patient Info |
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Please list all current medications, vitamins and supplements. Include dose and how often you take them. |
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Please list any medications you have been prescribed but are not currently taking. |
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Please list any medication allergies and what type of reaction you experienced. |
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Please describe any cholesterol medication you were previously taking but are no longer taking. Include the medication's name and dose, when you stopped taking it and why. |
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What is your current body weight? |
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What is your highest body weight in the past 5 years? |
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What is your lowest body weight in the past 5 years? |
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What is your target body weight? |
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Please describe any weight change in the last year and what you think is causing that change. |
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Do you have a Medical Power of Attorney? Please bring a copy to your first appointment. |
Yes
No |
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Do you have a Durable Power of Attorney? Please bring a copy to your first appointment. |
Yes
No |
Do you have a Living Will? Please bring a copy to your first appointment. |
Yes
No |
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Family History |
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Is your mother living? If not, what was her cause of death? |
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Please list any other medical problems that your mother has experienced. |
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Is your father living? If not, what was his cause of death? |
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Please list any other medical problems that your father has experienced. |
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How many siblings do you have? |
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Please list any medical problems that your siblings have experienced. |
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Please describe any heart problems experienced by your parents or siblings that was diagnosed before they were age 55. |
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Have any of your parents or siblings been told that they had high cholesterol? |
Yes
No |
Have there been any other patterns of disease in extended family members? (heart attacks, strokes, cancer, etc.) |
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Social History |
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Have you ever smoked regularly? |
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How many years? |
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How many packs a day? |
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When did you stop? |
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How frequently do you consume alcoholic beverages? |
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What types of alcoholic beverages do you drink? |
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How many alcoholic beverages do you consume in an average day? |
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How many alcoholic beverages do you consume in an average week? |
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Please describe any current or past recreational drug use. |
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Are you married? |
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How many children do you have? |
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What is your highest level of education? |
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What is your current occupation? |
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Please describe your exercise habits. |
Activity Ex. running, cycling, weight lifting |
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How many minutes per session? |
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How many sessions per week? |
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Activity |
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How many minutes per session? |
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How many sessions per week? |
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Activity |
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How many minutes per session? |
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How many sessions per week? |
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Activity |
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How many minutes per session? |
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How many sessions per week? |
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Sleep History |
How many hours of sleep do you get on an average night? |
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On average, how many nights a week do you get less than 7 hours of sleep? |
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Do you generally feel rested when you wake up and throughout the day? |
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Do you snore? |
Yes
No |
Have you ever had a sleep study? |
Yes
No |
Have you ever been recommended to use a CPAP machine? |
Yes
No |
If yes, how many hours per night are you able to use the CPAP? |
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If yes, how many nights per week are you able to use the CPAP? |
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Cardiovascular History |
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Have you ever had a heart attack? |
Yes
No |
Have you eve had a stent placed in your heart? |
Yes
No |
Have you ever had coronary artery bypass surgery? |
Yes
No |
Have you ever had a stroke or TIA? |
Yes
No |
Have you ever had stents placed or surgery on your carotid arteries? |
Yes
No |
Have you ever had stents placed or surgery on the arteries in your legs? |
Yes
No |
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Please provide additional details on any 'Yes' answers from this section. |
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Have you ever had a stress test? |
Yes
No |
Have you ever had a coronary artery calcium CT scan? |
Yes
No |
Have you ever had a cardiac catheterization? |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Obstetric and Gynecological History (if applicable) |
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How many times have you been pregnant? | <
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Have you ever had a miscarriage? If so, how many? |
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Have you ever had preeclampsia? |
Yes
No |
Have you ever had a baby born prematurely? |
Yes
No |
Have you ever had gestational diabetes? |
Yes
No |
Did you experience menopause before age 40? |
Yes
No |
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Please provide additional details on any 'Yes' answers from this section or any other pregnancy related complications you have had. |
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Dietary History |
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Do you attempt to follow a particular dietary pattern? Ex. low carb, vegan, vegetarian, intermittent fasting, etc. If so, please describe. | <
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What types of foods do you typically eat for breakfast? |
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What types of foods do you typically eat for lunch? |
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What types of foods do you typically eat for dinner? |
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What types of foods do you eat for snacks and how often? |
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How many sugar-sweetened beverages do you consume in an average week? Ex. non-diet soda, sweetened coffee/tea, fruit juice, etc. |
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Approximately how many meals a week are fast food? |
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Approximately how many meals per week are from a restaurant or take out (not fast food)? |
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Review of Systems: Mark Yes for any item experienced in the past 2 years. |
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Weight change (planned or unplanned) |
Yes
No |
Convulsions or Seizures |
Yes
No |
Frequent Headaches |
Yes
No |
Dizziness and/or Unsteadiness on your feet |
Yes
No |
Fainting |
Yes
No |
Do you wear glasses or contacts? |
Yes
No |
Change in Hearing |
Yes
No |
Sinus Issues |
Yes
No |
High Blood Pressure |
Yes
No |
Chest Pain at rest |
Yes
No |
Chest Pain during exercise |
Yes
No |
Does your heart ever race or skip beats? |
Yes
No |
Do you have a heart murmur? |
Yes
No |
Are you short of breath while exercising? |
Yes
No |
Are you short of breath at night? |
Yes
No |
Are you short of breath at rest? |
Yes
No |
Swelling of feet or ankles? |
Yes
No |
Frequent Cough |
Yes
No |
Coughing up Blood |
Yes
No |
Bronchitis |
Yes
No |
Pneumonia |
Yes
No |
Pleurisy |
Yes
No |
Asthma or Wheezing |
Yes
No |
Emphysema |
Yes
No |
Abdominal Pain |
Yes
No |
Frequent Nausea |
Yes
No |
Vomiting Blood |
Yes
No |
Bloody or Black Stools |
Yes
No |
Frequent Diarrhea |
Yes
No |
Frequent Constipation |
Yes
No |
Hepatitis or Jaundice |
Yes
No |
Cirrhosis of Liver |
Yes
No |
Pancreatitis |
Yes
No |
Difficulty or Pain during Urination |
Yes
No |
Blood in Urine |
Yes
No |
Diabetes |
Yes
No |
Thyroid Problem |
Yes
No |
Cancer (any type) |
Yes
No |
Blood Disorder |
Yes
No |
Fever or chills |
Yes
No |
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Please comment on any 'Yes' answers from this section. |
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Click Here to Submit Form |
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