Cardiovascular Registration Form -

EMERGENCY NOTICE: If you are currently experiencing chest pain, pressure, shortness of breath, jaw or arm pain, or any symptoms of a heart attack or stroke, do NOT complete this form. Call 911 immediately.

Patient Information

Patient Name

First

Last

Date of Birth

Age

Biological Sex

Phone Number

Email Address

Best Way to Reach You

New or Returning Patient?

How Did You Hear About Us?

Referring Physician Name (if applicable)

Cardiovascular History

Diagnosed Cardiovascular Conditions

Cardiac Tests or Procedures You Have Had

Describe Any Cardiac Procedures and Approximate Dates

Family History of Heart Disease

Describe Your Family Cardiac History

Current Symptoms

Describe Your Symptoms in Your Own Words

Advanced Lipid & Inflammatory Markers

Dr. Thomas goes beyond standard cholesterol panels. Share recent results, or select Never tested and labs will be ordered at your consultation.

ApoB (Apolipoprotein B)

Lp(a) – Lipoprotein Little a

Oxidized LDL (oxLDL)

Homocysteine

hs-CRP (High-Sensitivity C-Reactive Protein)

Standard LDL Cholesterol

HDL Cholesterol

Triglycerides

Other Lab Results You'd Like Dr. Thomas to Know About

Blood Pressure History

Blood Pressure Status

Most Recent Blood Pressure Reading

Blood Pressure Medications Currently Taking

ACE inhibitor (Lisinopril, Ramipril)
ARB (Losartan, Valsartan)
Beta blocker (Metoprolol, Atenolol)
Calcium channel blocker (Amlodipine)
Diuretic (HCTZ, Chlorthalidone)
Aldosterone antagonist (Spironolactone)
Other BP medication
Not on any BP medication

Heart Arrhythmia History

Have You Been Diagnosed With a Heart Arrhythmia?

Arrhythmia Medications Currently Taking

Describe Your Arrhythmia History and Known Triggers

Diabetes & Blood Sugar

Blood Sugar Status

Most Recent HbA1c Result

Diabetes Medications Currently Taking

Cholesterol & Cardiac Medications

Cholesterol Medications

Blood Thinners & Antiplatelet Medications

All Other Current Medications (name and dose)

Drug Allergies or Adverse Reactions

Current Supplements and OTC Medications

Lifestyle & Risk Factors

Current Weight (lbs)

Height

to Arrhythmia? Quality

Average Sleep Hours Per Night

Tobacco Use

Alcohol Use

Exercise Frequency

Stress Level

Sleep Apnea Diagnosis

Diet Quality

Your Goals & Concerns

Primary Goals for This Visit

What Is Your Biggest Concern About Your Heart Health?

What Has Been Missing From Your Cardiac Care So Far?

Consent and Signature

Please read and confirm each statement before submitting.

Accuracy

I confirm the information above is accurate to the best of my knowledge.

Additional Labs

I understand Dr. Thomas will order additional lab work based on my history and goals at my initial consultation.

Not Emergency Care

I understand this form does not replace emergency care. I will call 911 immediately if I experience chest pain, shortness of breath, or symptoms of a heart attack or stroke.

Contact Consent

I consent to Dr. Thomas’s team contacting me by phone or email to schedule my consultation.

Electronic Signature (type your full legal name)

Today's Date