Deaconess Hospital

$Lori\$

Wolf MiniMaze procedure questionnaire for information about your
atrial fibrillation and medical history.

Information we must have faxed to us for review:

1. Your most recent cardiac tests and procedures (EKG, echocardiogram, cardiac catheterizations and stress tests). Reports must be within the last 6 months.

2. A list of current medications and the dosages, especially any anti- arrhythmics AND Coumadin

3. Your past medical and surgical history

4. If you have a pacemaker- specify type, brand and model (if possible)

5. Your current height and weight

6. Any other procedures used to treat your atrial fibrillation (i.e.cardioversions,catheter ablations)

7. We need a copy of your cardiac catheterization on a CD-Rom.
Any information or reports on cardioversions or ablation. Reports:
Any information on operative reports from any previous heart surgeries, any VQ scans, GXT ... Reports, and/or pulmonary history, if any.

In order to provide quick, accurate, and consistent correspondence,please include your
telephone numbers, current mailing address and e-mail address (if you have one).

THIS IS A SECURE PAGE ALL INFORMATON WILL KEPT CONFIDENTIAL
AS PRESCRIBED BY THE HIPAA ACT

MEDICAL HISTORY QUESTIONNAIRE

YOUR PERSONAL INFORMATION

Today's Date: (mm/dd/yyyy)

Your Name:
Your Address:
Street Apt #
City State Zip code

Date of birth: (mm/dd/yyyy)
Age:
Gender : Male Female
Weight in pounds
Height: feet inches

Social Secutity Number xxx-xx-xxxx
HOME Phone Number with area code:
WORK Phone Number with area code:
CELL Phone Number with area code:
FAX Phone number with area code:
EMAIL ADDRESS:

Patient employer
Patient Occupation

PRIMARY CARE PHYSICIAN INFORMATION

Your Doctor's:
Name:
Address:
Street Suite #
City State Zip code

Telephone Number with area code:
FAX Number with area code:

Please make sure to include you Doctor's FAX number.

CARDIOLOGIST INFORMATION

Your Cardiologist's:
Name:
Address:
Street Suite #
City State Zip code

Telephone Number with area code:
FAX Number with area code:

Please make sure to include you Cardiologist's FAX number.

PERSON WHO WILL BE COMING WITH THE PATIENT FOR THE PROCEDURE

Name:
Relatioship
Telephone Number with area code:

YOUR INSURANCE COMPANY INFORMATION

Please fax a copy of your insurance card, front and back, to 513-584-1538 attention Audrey

Name:
Address: Suite #
City: State Zip Code
Phone Number with area code:
Fax Number with area code:
Subscribers Name:
Members Name:
Group Name:
Coverage Type:
ID number:
Group Number:
Effective Date: (mm/dd/yyyy)
Group Name-(i.e. employer name):

Your Local Pharmacy Information

Name of Pharmacy
Phone number with area code:
FAX number with area code:

Please, check all boxes that apply to you

If you do not understand a question, then it probably means that you do not have the condition.

Check the boxes that pertain to your situation:

Do you have a cardiac history? Yes No

Hypertension (High blood pressure) Year Diagnosed (yyyy)

LVH (enlarged heart) without hypertension

Coronary artery disease

Angina (Chest pain on exertion)

Previous Myocardial infarction (Heart attack) Date: (mm/dd/yyyy)

ldiopathic cardiomyopathy

Tachycardia mediated cardiomyopathy

Hypertrophic cardiomyopathy

Heart Failure

Valvular heart disease Date diagnosed (mm/dd/yyyy)

Endocarditis

Pericarditis

Congenital heart disease Type

Any previous heart surgery Type

Check the boxes that pertain to your situation:

Do you have a pulmonary history? Yes No

Chronic obstructive pulmonary disease.

What intensity: ONLY CHECK ONE
Mild
Moderate
Severe
-------------------------------------------------------------

Emphysema.

What intensity: ONLY CHECK ONE
Mild
Moderate
Severe
-------------------------------------------------------------

Asthma

Intensity: ONLY CHECK ONE
Mild
Moderate
Severe
-------------------------------------------------------------

Previous Pulmonary embolism

-------------------------------------------------------------------------------------------

Check the boxes that pertain to your situation:

Do you have a vascular history? Yes No

Transient ischemic attack Year Diagnosed (yyyy)

Reversible Ischemic Neurological Deficit Year Diagnosed (yyyy)

Stroke Year Diagnosed (yyyy)

Permanent neurological deficit Specify

Renal insufficiency

Peripheral vascular disease

Deep vein thrombosis

Check the boxes that pertain to your situation:

Do you have an endocrine disease? Yes No

Diabetes Mellitus Year Diagnosed (yyyy)

Are you on Insulin? Yes No

Hypothyroid? ONLY CHECK ONE
Hyperthyroid?

Atrial Fibrillation History

What condition does your doctor say you have?

Are you in Atrial Fibrillation all of the time? Yes No
If yes, for how long?

Or does your A Fib come and go? Yes No
If it comes and goes, how frequent are the episodes?

How Long have you had atrial fibrillation?
Are you aware of it when you are in AF? Yes No

Have you had a previous cardioversion? Yes No
If yes, when was the last one? (mm/dd/yyyy)

Have you had a previous EP Study? Yes No
If yes, when was the last one? (mm/dd/yyyy)

Have you had a previous cardiac ablation? Yes No
If yes, when was the last one? (mm/dd/yyyy)

Have you had a previous echocardiogram? Yes No
If yes, when was the last one? (mm/dd/yyyy)

Have you had a previous stress test? Yes No
If yes, when was the last one? (mm/dd/yyyy)

Have you had a previous cardiac catheterization? Yes No
If yes, when was the last one? (mm/dd/yyyy)

Do you have a pacemaker? Yes No
If yes, please specify type, brand and model (if possible)

List of All Current Medications:

Medication Name: Dosage: Frequency: Reason:

Are you allergic to any medications? Yes No

If your answer is yes, please list the medications that you are allergic to in the window below.

Surgical Procedures

List all surgical procedures you have had and the year they were performed.

Surgical Procedure: When?: (mm/dd/yyyy)

General Anesthesia

Have you ever had general Anesthesia? Yes No

Any complications with general Anesthesia? Yes No

If yes, please explain in detail, in the comment box below.

Is there any other significant medical or surgical history that you think we should know about?
If so, please describe them in the window below.

It is important that we get copies of reports of any of these procedures, and a list of current medications and the dosages, especially anyanti-arrhythmics AND Coumadin dose.
Please E-mail reports to nessie.hicks@gmail.com
or fax information to 859-291-0024 - Attention: Nessie

. Click the "SUBMIT" button to submit your questionnaire.

IMPORTANT- ONLY CLICK THE SUBMIT BUTTON
ONE TIME AND WAIT FOR A NEW PAGE TO SHOW.

.Click to clear the questionnaire, to start over.

CLICK HERE TO RETURN TO THE DEACONESS ATRIAL FIBRILLATION CENTER