Cardiovascular Patient Registration -

Patient Registration

Cardiovascular Patient
Registration Form

For patients seeking cardiovascular risk assessment, advanced lipid testing, hypertension management, arrhythmia evaluation, and inflammation-driven cardiac care. Please complete all sections as thoroughly as possible.

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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.

🔒 Your information is sent securely and directly to Dr. Thomas’s clinical team. A team member will contact you within one business day to schedule your initial consultation.

Patient Information

First name

Last name

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 (check all that apply) 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

Current symptoms (check all that apply)

Describe your symptoms in your own words

Advanced Lipid and Inflammatory Markers

Dr. Thomas goes beyond standard cholesterol panels to assess true cardiovascular risk. Please share any recent advanced lab results below. If you have not been tested, select “Never tested” — Dr. Thomas will order what is needed 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 would 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 Other BP medication Not on any BP medication

Heart Arrhythmia History

Have you been diagnosed with a heart arrhythmia?

Arrhythmia medications currently taking

Beta blocker (Metoprolol, Atenolol) CCB (Diltiazem, Verapamil) Antiarrhythmic (Flecainide, Amiodarone) Blood thinner (Eliquis, Xarelto, Warfarin) Digoxin None

Describe your arrhythmia history and any known triggers

Diabetes and Blood Sugar

Blood sugar status

Most recent HbA1c result

Diabetes medications currently taking

Metformin SGLT2 inhibitor (Jardiance, Farxiga) DPP-4 inhibitor (Januvia) Sulfonylurea (Glipizide, Glimepiride) Insulin Not on diabetes medication

Cholesterol and Cardiac Medications

Cholesterol medications

Statin (Atorvastatin, Rosuvastatin) Ezetimibe (Zetia) PCSK9 inhibitor (Repatha, Praluent) Fibrate (Fenofibrate) Niacin Prescription fish oil (Vascepa, Lovaza) Not on cholesterol medication

Blood thinners and antiplatelet medications

All other current medications (name and dose)

Drug allergies or adverse reactions

Current supplements and OTC medications

Lifestyle and Risk Factors

Current weight (lbs)

Height

Avg sleep hours per night

Tobacco use

Alcohol use

Exercise frequency

Stress level

Sleep apnea diagnosis

Diet quality

Your Goals and Concerns

Primary goals for this visit (check all that apply)

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 below before submitting.

Electronic signature (type your full legal name)

Today’s date

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Registration Received!

Thank you for registering with Sure Success Wellness Center. Dr. Thomas’s team will review your cardiovascular history and contact you within one business day to schedule your initial consultation.

Important: If you experience chest pain, shortness of breath, or any symptoms of a heart attack or stroke before your appointment — call 911 immediately. Do not wait.

For non-emergency questions please call us at (317) 253-7795.

Cardiovascular Patient Registration

Cardiovascular PatientRegistration Form

Registration Received!

Cardiovascular Patient
Registration Form