Congenital Heart Disease Intake Form
Please provide your medical history and current heart-related information before your appointment.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Sex at Birth
Female
Male
Intersex
Prefer not to say
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Congenital Heart Disease History
Congenital heart disease diagnosis or defect type
*
Please Select
Atrial septal defect (ASD)
Ventricular septal defect (VSD)
Patent ductus arteriosus (PDA)
Tetralogy of Fallot
Coarctation of the aorta
Transposition of the great arteries
Pulmonary stenosis
Atrioventricular septal defect
Single ventricle physiology
Other
Date of diagnosis
 -
Month
 -
Day
Year
Date
Prior cardiac surgery or catheter-based procedure
*
Yes
No
Current heart-related symptoms
Shortness of breath
Chest pain
Fatigue
Palpitations
Fainting
Cyanosis
No current symptoms
Current Treatment and Background
Current medications
Known allergies
None known
Medication allergies
Food allergies
Latex allergy
Environmental allergies
Other
Family history of congenital heart disease or inherited heart conditions
*
Yes
No
Brief description of family history (if yes)
Emergency contact name
*
Emergency contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: