Cardiac Assessment and Treatment Intake Questionnaire Form
Please complete this questionnaire to help us understand your cardiac health and treatment needs. All questions are non-sensitive and intended for intake and assessment purposes only.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Email
*
example@example.com
Appointment Date and Time
*
Please rate the severity of your current cardiac symptoms
*
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
Which of the following symptoms have you experienced recently? (Select all that apply)
*
Chest pain or discomfort
Shortness of breath
Palpitations
Fatigue
Swelling in legs or ankles
Dizziness or fainting
Other
In the past month, how often have you engaged in physical activity (e.g., brisk walking, cycling)?
*
Daily
Several times a week
Once a week
Rarely
Never
Do you currently smoke tobacco products?
*
Yes
No
Former smoker
Personal and Family Cardiac History
Rows
You
Family Member
Heart attack
1
2
High blood pressure
3
4
High cholesterol
5
6
Stroke
7
8
Arrhythmia
9
10
Please list any current medications or relevant notes (optional)
Submit Assessment
Should be Empty: