| PATIENT:_________________________________________________ | |||
| SOCIAL SECURITY #:_______________________________________ | |||
| DATE OF BIRTH:____________________________________________________ | |||
To the Doctor: Please complete the following report attaching copies of lab reports. Please use the back of the form if additional space is needed. |
| 1. | a. | Current diagnosis:____________________________________ | |
| b. | On what date was this diagnosis first made? ______________ | ||
| c. | What is the date of onset, if different? _______________ | ||
| d. | How long have you been treating the condition? ____________ | ||
| e. | Date of most recent examination? __________________ | ||
| f. | At that time, what was the patient's height ___________ weight___________? | ||
2. | List the last three blood pressure findings and the dates: | ||
| 3. | Physical findings (give dates): | ||
| a. | Pulse rate _______________________________ | ||
| b. | Rhythm _____________________________ | ||
| c. | Liver: Normal Tender Enlarged (Degree) _____________ (Please cirlce one) | ||
| d. | Orthopnea: _____________________________ | ||
| e. | Cyanosis: _____________________________ | ||
| f. | Ascites: _____________________________ | ||
| g. | Edema: Peripheral? Yes _____ No ______ Pulmonary? Yes ______ No ______ If yes, describe any limitations: | ||
| h. | BUN (give dates): _____________________________ | ||
| i. | Clubbing: _____________________________ | ||
| j. | Resonance: _____________________________ | ||
| k. | Chest x-ray findings: _____________________________ | ||
4. | Has the hypertension resulted in: | ||
| Retinopathy? Yes ______ No ______. If yes, what grade? _____________ | |||
5. | Is there any hypertensive heart disease? Yes _____ No ______ If yes, answer the following: | ||
| a. | Findings of periodic EKGs (indicate dates): | ||
| b. | Findings of stress (treadmill) tests (indicate dates): | ||
| c. | Other findings: | ||
| NOTE: Was digitalis or any other cardiac medication given at time of above tests? Yes ______ No ______. Please send copies of EKG TRACINGS and stress test results. If you cannot make copies, we will xerox the originals and return them to you immediately. | |||
6. | Is there peripheral neuropathy? Yes _____ No _____ If yes, please describe: | ||
| Date Report Completed: | ______________________________ |
| Signature of Physician: | ______________________________ |
| Physician Name: | ______________________________ |
| Address: | ______________________________ |
| Telephone: | ______________________________ |
| Specialty: | ______________________________ |