SpecialtyHealth, Inc.

Cardiac Wellness Program©

Cardiac Health History Questionnaire

Section 1 – Participant Information TODAY’S DATE

NAME (LAST) (FIRST) (MI)
AGE BIRTHDATE Gender: ! MALE ! FEMALE
HOME PHONE # WORK PHONE #
E-MAIL ADDRESS CELL PHONE #
CURRENT OCCUPATION: _____________
YEARS IN THIS OCCUPATION: EMPLOYER ____________________________
EMPLOYER ADDRESS: ______________________________________________________________________

PRIMARY CARE PHYSICIAN (If applicable):

NAME
ADDRESS (STREET AND NUMBER)
CITY STATE ZIP CODE PHONE
Authorization
I hereby authorize the physicians and staff involved in SpecialtyHealth’s Cardiac Wellness Program to utilize my
medical information obtained through the Cardiac Wellness Program for the purpose of research. Research
may include individual case studies and/or compilations of group/population data, which may be published
and/or presented in lectures. All personal and medical information will be kept confidential. A personal ID will
be assigned to each individual participant to protect their privacy.

I DO authorize my medical and personal information to be used as part of research.

(Initial)

I DO NOT authorize my medical and personal information to be used as part of research.

(Initial)

SIGNATURE DATE

Consent to Release Medical Information

According to the HIPAA compliance for protected health information (PHI), it is necessary to provide
SpecialtyHealth Clinic with the name(s) of the following individual(s) with whom they can share my protected
health information (PHI). It is with my informed consent that these individuals are able to speak with, give written
prescriptions and orders for procedures to, and discuss health care options with if I am unable to do so. It is also
my understanding that I may revoke this consent at any time as long as the revocation is in writing with a
signature, effective date and is received in the office of SpecialtyHealth Clinic.

PATIENT NAME: DATE:

ADDRESS:
PATIENT SIGNATURE:

DESIGNATED INDIVIDUAL(S) AUTHORIZED TO RECEIVE PERSONAL HEALTH NFORMATION (PHI):

NAME RELATIONSHIP TO PATIENT

Reproduction is forbidden without SpecialtyHealth 1

Permission from SpecialtyHealth, Inc. 350 W. Sixth Street, Suite 2-D
Cardiac Wellness Program © Reno, NV 89503
Rev. 11-17-08 (775) 329-9920
 SpecialtyHealth, Inc.
Cardiac Wellness Program©
Cardiac Health History Questionnaire

Name _____________________________________ Date ________________________

Section 2 – Personal Health History

Allergies (such as to medication, food, etc.):

Current Health Problems:

Currently Prescribed Medications:

Currently used over-the-counter products (such as vitamins, supplements or aspirin):

Past Surgeries:

Other Health History:__________________________________________________________________________

___________________________________________________________________________________________

1. Have your ever had or been diagnosed with the following?

___ Heart Attack (myocardial infarction)
___ Angina pectoris or coronary artery disease
___ Coronary artery surgery (angioplasty, stent, or coronary bypass)
___ Stroke (TIA “small stroke” or major stroke) or coronary artery obstruction
___ Peripheral artery disease (PAD, artery blockage in the legs)
___ Aortic aneurysm
___ Diabetes mellitus (sugar diabetes)

2. Tobacco use?
___ Do you currently smoke cigarettes
___ If you have quit smoking, has it been less than a month
___ Any past history of tobacco use?
___ Do you currently use any tobacco products?

3. Are you currently taking medications for any of the following conditions?
___ High blood sugar
___ Elevated blood triglycerides
___ Low level of “good” cholesterol (HDL-cholesterol)
___ High level of “bad” cholesterol (LDL-cholesterol)

Reproduction is forbidden without SpecialtyHealth 2

Permission from SpecialtyHealth, Inc. 350 W. Sixth Street, Suite 2-D
Cardiac Wellness Program © Reno, NV 89503
Rev. 11-17-08 (775) 329-9920
 SpecialtyHealth, Inc.
Cardiac Wellness Program©
Cardiac Health History Questionnaire

Name _______________________________________________________________ Date _______________________

4. Family history?
___ Did your father or a brother develop coronary artery disease or have a heart attack before the age of 55
___ Did you mother or sister develop coronary artery disease or have a heart attack before the age of 65

Do you currently have any of the following: Yes or No for each

Yes No Yes No
! ! Unexplained Weight Gain ! ! Chronic Cough
! ! Unexplained Weight Loss ! ! Wheezing
! ! Decreased Energy or Lethargy ! ! Chest Discomfort or Pain with Breathing
! ! Nausea or vomiting ! ! Shortness of Breath with Exertion
! ! Dental Problems ! ! Difficulty Breathing while Lying Flat
! ! Heartburn or Acid Reflux ! ! Swelling of Ankles
! ! Nervousness or Anxiety ! ! Depression
! ! High Blood Pressure ! ! Palpitations or Irregular Heart Beat
! ! Dizziness or fainting spells ! ! Pain in calf when walking that stops with rest
! ! ! !

Section 3– Nutrition

In a typical day, indicate how many servings you eat or drink of the following:
Servings Circle the type you use
Breads, cereals, pasta or rice Whole grain White
Fruits Fresh Frozen Canned
Vegetables Fresh Frozen Canned
Dairy products (milk, yogurt) Non-fat Low-fat Regular
Caffeine drinks Diet Regular
Water (8 oz.)

In a typical week, indicate how many servings you eat of the following:
Servings
Eggs
Nuts and Seeds
Legumes (beans, peas, lentils)
Cheese
Fish

Reproduction is forbidden without SpecialtyHealth 3

Permission from SpecialtyHealth, Inc. 350 W. Sixth Street, Suite 2-D
Cardiac Wellness Program © Reno, NV 89503
Rev. 11-17-08 (775) 329-9920
 SpecialtyHealth, Inc.
Cardiac Wellness Program©
Cardiac Health History Questionnaire

Name _______________________________________________ Date _______________________

Red Meats
Chicken

Which of the following do you typically eat and/or use in cooking? Circle all that apply.
Butter Stick margarine Trans fat-free margarine Oil-based salad dressing
Olive oil Canola oil Soybean Oil Shortening
Lard Meat drippings Olives Avocados Mayonnaise

In a typical week:
1. How often do you eat breakfast? (Circle) Daily 4-6 Times 2-3 Times Once Never
2. How often do you eat high-fat foods (like hamburgers, cheeseburgers, hot dogs, bacon, fried chicken or
fish, fries, whole milk, sausage or chips)? (Circle) Daily 4-6 Times 2-3 Times Once Never
3. How many meals do you eat fast food?
4. How often do you add salt or eat salty foods? (Circle) Daily 4-6 Times 2-3 Times Once Never
5. How often do you eat highly refined foods (like chips, pastry, cookies, candy, or regular soda)?
(Circle) Daily 4-6 Times 2-3 Times Once Never
6. How many times do you eat out? Breakfast Lunch Dinner
7. Where do you usually eat out? Check all that apply: _____ Fast Food ____ Sit-down Restaurant ____
Take out (Chinese, pizza, etc.) _____ Convenience Store (mini-mart, 7-11) _____ Other:

Section 4– Physical Activity

In a typical week:
1. How often do you engage in moderate activity, such as brisk walking, bicycling, vacuuming, or gardening?
Moderate activity results in light sweating and mild increase in heart rate.
(Circle) None or rarely 1-2 days/week 3-4 days/week 5-7 days/week
2. How long do you engage in moderate activity?
(Circle) Less than 15 minutes 15-29 minutes 30-59 minutes Over one hour
3. How often do you engage in strenuous activity, such as running, aerobic exercise or heavy physical
work? Strenuous activity results in heavy sweating and large increase in pulse or breathing rate.
(Circle) None or rarely 1-2 days/week 3-4 days/week 5-7 days/week
4. How long do you engage in strenuous activity?
(Circle) Less than 15 minutes 15-29 minutes 30-59 minutes Over one hour

Reproduction is forbidden without SpecialtyHealth 4

Permission from SpecialtyHealth, Inc. 350 W. Sixth Street, Suite 2-D
Cardiac Wellness Program © Reno, NV 89503
Rev. 11-17-08 (775) 329-9920
 SpecialtyHealth, Inc.
Cardiac Wellness Program©
Cardiac Health History Questionnaire

Name ________________________________________________ Date ________________________

Indicate your current type of activity: Days Per Week Duration

Aerobics (fast walking, jogging, bicycling, etc. minutes

Strength training (weight lifting) minutes
Stretching minutes
Other minutes

List any current limitations on physical activity:

Do you currently belong to a health club or regularly participate in exercise classes? (Circle) Yes / No

List the barriers or what gets in the way of engaging in regular physical activity:
Yes No
! ! Not enough time / too busy
! ! Not enough money
! ! Safety concerns
! ! No place to be active or walk
! ! Lack of support from others
! ! Stress
! ! Do not like to exercise
! ! Pain
! ! Too tired
! ! Work schedule
! ! Other – List:

Section 5 – Readiness Assessment

On a scale from 1 (very low) to 10 (very high), please answer the following:
1. How important is changing your lifestyle in controlling your weight, lowering your blood sugar, reducing your blood
pressure or decreasing cholesterol? _
2. How interested are you in making lifestyle changes to improve your health? ___
3. How confident are you that you can make the necessary lifestyle changes to meet your health goals? ____

Stages of Change
Improving your current level of health often requires lifestyle change such as increasing physical activity, changing your diet, or
engaging in new behaviors. Please review the stages of change below as described by Prochaska and DiClemente. Once
reviewed, indicate your readiness to make lifestyle changes in the boxes below for each of the areas listed.

Reproduction is forbidden without SpecialtyHealth 5

Permission from SpecialtyHealth, Inc. 350 W. Sixth Street, Suite 2-D
Cardiac Wellness Program © Reno, NV 89503
Rev. 11-17-08 (775) 329-9920
 SpecialtyHealth, Inc.
Cardiac Wellness Program©
Cardiac Health History Questionnaire

Pre-contemplation – I’m not interested in making a change. I’m not sure I even need to make a change.
Contemplation – I know I should change, but I don’t really want to yet. I’ll think about it.
Preparation – I want to change, but I don’t know how and I need some help to get started.
Action – I have recently made some changes in this area, but am sometimes tempted to fall off track.
Maintenance – I made changes in this area and have continued to keep on track.

Pre- Not
Contemplation Preparation Action Maintenance
contemplation Applicable
Quit
Smoking
Change
Diet
Increase
Activity
Lose
Weight

Please bring your completed form to your appointment. Thank you!

Patient signature ______________________________________ Date ______________

Review by: ____________________________________________ Date _____________

Reproduction is forbidden without SpecialtyHealth 6

Permission from SpecialtyHealth, Inc. 350 W. Sixth Street, Suite 2-D
Cardiac Wellness Program © Reno, NV 89503
Rev. 11-17-08 (775) 329-9920