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About
Services
Healthy Heart
Pre Visit
- For Doctors
- For Patients
Contact

Stroke

Women Face Unique Risks for High Blood Pressure and Stroke

DALLAS, May 3, 2021 — Women have a lot on their plates, and sometimes important self-care can take a back seat to work, family and other obligations.

Women Face Unique Risks for High Blood Pressure and Stroke Read More »

Collingwood Cardiology &
Internal Medicine

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Contact Info

1 Huron Street, Suite 201 Collingwood, Ontario L9Y 1C3

705-444-1648

705-444-1909

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Medication List

Name

DOB

Pharmacy

Phone Number

Please List Medications *

14107

COVID-19 Questionaire

Name

D.O.B.*

Have you been around anyone with COVID-19?*

YES NO

Have you been notified by the COVID phone app?*

YES NO

Have you travelled or been with anyone who has travelled outside of the country?*

YES NO

Do you have a cough, cold, or fever?*

YES NO

Are you short of breath (short term/long term? - Are you here for this reason?*

YES NO

Are you congested?*

YES NO

Do you lack a sense of taste or smell?*

YES NO

Have you been asked to self isolate?*

YES NO

Are you awaiting COVID test results?*

YES NO

20402

Your temperature will be taken before entry into our office. Entry is granted to those wearing a mask or face cover as per the Simcoe Muskoka Health Unit.

Consult Questionaire

Name

D.O.B*

Home Address

Preferred Phone Number

Height

Weight

Allergies:

Family Doctor

Pharmacy

Lab Location

Current Complaints?*

Have you ever seen a Cardiologist before?*

Have you ever been diagnosed with: (Please select all that apply)

Diabetes High Blood Pressure High Cholesterol

Are you a current cigarette smoker?

NO YES

How many packs a day do you smoke?

If you have quit smoking, when was the quit date?

How much did you previously smoke?

Please select if you RECENTLY had

Chest Pains or Pressure with EXERCISE Chest Pains or Pressure with STRESS Chest Pains or Pressure with AT REST Palpitation, Irregular Heartbeats, Fast or Slow Heart Rates Fainting or Near Faintings or Dizziness Swelling of Your Legs Leg Pain or Cramps When Walking

Please select if you have EVER had

Heart Attack/MI (myocardial Infarction) Angina Heart Murmur Rheumatic Fever Congestive Heart Failure or Heart Enlargement Atrial Fibrillation/Irregular Heart Beat Kidney Failure

If yes to any of the above, please list with dates

Have you had any of the following: (Please select all that apply)

A Stress Test An Echocardiogram A Heart Catheterization or Angioplasty, or Stent Heart Bypass, Coronary, or Valve Surgery A Pacemaker or Defibrillator

If yes to any of the above, please list with dates

List ALL Prescriptions and Dosage (How Often?)

*Do you take ASA 81 mg od?

Yes No

Vitamins/Supplements/Herbal or Natural Supplements

SOCIAL HISTORY & FAMILY HISTORY: Occupation

Marital Status

Education Level

How much alcohol do you drink a week?

How much coffee, tea or cola do you drink daily?

Do you exercise?

Has a family member ever had a heart attack, angina, or other heart problems? (If yes to any, please describe)

SURGERY HISTORY/ HOSPITALIZATIONS: Please list the names and year of any operations OR hospitalizations which you have had

Please list any serious illnesses or injuries which you have had that DID NOT require hospitalization

MEDICAL REVIEW OF SYSTEMS: Have you ever had any of the following? (Please select all that apply)

A stroke or small stroke Frequent or severe headaches A seizure (convulsion) Difficulty with speech Anemia Problems with lungs, including wheezing or asthma Problems with liver Problems with kidneys Arthritis Depression or a pyschiatric condition varicose veins Easy bleeding or bruising A history of ulcers A history of hiatus/hiatal hernia Blood in stools or black/tarry stools Diarrhea or constipation Recent fever or chills Trouble starting to urinate Blood in urine Kidney stones Get up frequently at night to urinate Snoring loudly at night Blood clots in lungs, legs or elsewhere

Date

65053

Follow Up Questionaire

Dear Patient,

Please review your demographic information that we have on file for you, and make us aware of any changes involving your personal information. Thank you.

Name

D.O.B*

Home Address

Preferred Phone Number

Height

Weight

Allergies:

Family Doctor

Pharmacy

Lab Location

SINCE YOUR LAST VISIT HAVE YOU HAD: CHEST PAIN?

NO YES

SHORTNESS OF BREATH?

NO YES

PALPITATIONS?

NO YES

LIGHT HEADEDNESS OR DIZZINESS?

NO YES

BLACKOUTS

NO YES

SWELLING IN LEGS

NO YES

WEAKNESS OR FATIGUE

NO YES

ARE YOU SMOKING CIGARETTES?

NO YES

ARE YOU EXERCISING?

NO YES

DO YOU EXPERIENCE PAIN, ACHING OR CRAMPS IN YOUR CALVES OR BUTTOCKS WHEN WALKING?

NO YES

IF YES, WHICH LEG?

LEFT RIGHT BOTH

DEGREE OF DIFFICULTY

NONE SLIGHT SEVERE

SINCE YOUR LAST VISIT: HAVE YOU BEEN HOSPITALIZED?

NO YES

(If Yes) Date:

ANY TESTS DONE?

Any new medical or surgical problems or other new symptoms since your last visit?

When was your last cholesterol testing?

Where

Pleast list any CHANGES in your medications: Drug/mg/freq

*Do you take ASA 81 mg od?

Yes No

Date

77005

Services Required

Patient Name

Healthcard Number

DOB*

Address

Home Phone

Cell Phone

Work Phone

Referring Doctor

Fax Number

OHIP Billing #

Reason For Referral

SERVICE REQUIRED

2D ECHO - DOPPLER - Referring physicians MUST select an indication for testing:

STRESS ECHOCARDIOGRAM - Referring physicians MUST select an indication for testing:

EXERCISE ECG HOLTER MONITOR - 24 HR - 48 HR - 7 DAY - 14 DAY - 7 DAY ICENTIA (WATERPROOF) BP MONITOR ($75.00 CASH OR CHEQUE) ECG

83497

Consult-Follow up Referral

Patient Label

Reason For Consultation

Medication's Currently ON

Please Provide Relevant Information: (This determines the speed in which your patient will be seen.)

History (Include or attach a list of current medication, allergies and any cardiac test results.)

Allergies

Signature/Billing #

Date

74761