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Your Email Address:__________________
Date of Birth:_______________________
Gender: Male Female
Primary Care Physician Name, Address and Phone:__________________
Emergency Contact Name:______________
What seems to be the problem?
What is the reason for consultation?
Do you have high blood pressure or are you taking a blood pressure medication?
I Don't Know
I have never smoked
I used to smoke, but have quit
I Don't Know
Yes, I was diagnosed prior to age 21
I have a moderate level of stress
I have a high level of stress
Moderately Active (about 30 minutes of activity 3 days per week)
Moderate Drinker (1-2 drinks per day)
Heavy Drinker (3 or more drinks per day)
I don't drink
These are basic questions.
There are many more.
When should you call Emergency Medical Services?
Do you have any of these symptoms, signs, or problems?
New chest pain or discomfort that is severe, unexpected, and occurs with shortness of breath, sweating, nausea, or weakness.
Palpitations with a resting adult heart rate of more than 100 per minute.
Palpitations with a resting adult heart rate of more than 100 per minute five minutes after brisk walk or exercise.
Shortness of breath not relieved by rest.
Fainting spell with loss of consciousness.
New irregular heartbeat.
Chest pain or discomfort during activity that is relieved with rest.
Difficulty breathing during regular activities or at rest.
Constant dizziness or lightheadedness.
Nausea and vomiting.