Specify if the patient has ever had any of the following conditions:
Congenital heart disease, defect, or heart murmur? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button 
.
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Heart Defect: Atrial Septal Defect.
Heart Defect: Ventricular Septal Defect.
Heart Defect: Atrioventricular Septal Defect.
Heart Defect: Ventricular Defect.
Heart Defect: Patent Ductus Arteriosus.
Stenosis: Aortic Valve Stenosis.
Stenosis: Mitral Valve Stenosis.
Stenosis: Pulmonary Valve Stenosis.
Heart Structure Defects: Coarctation of Aorta.
Heart Structure Defects: Tetralogy of Fallot.
Heart Structure Defects: Pulmonary Atresia.
Heart Structure Defects: Transposition of the Great Arteries.
Heart Murmur: Innocent Heart Murmur (No follow up by MD).
Heart Murmur: Abnormal Heart Murmur (Monitored by MB).
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Heart disease or congestive heart failure? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Heart Valve Abnormality: Aortic Valve (Regurgitation, Stenosis, etc...).
Heart Valve Abnormality: Mitral Valve (Regurgitation, Stenosis, etc...).
Heart Valve Abnormality: Pulmonary Valve (Regurgitation, Stenosis, etc...).
Heart Arrythmia: Adams-Stokes Disease.
Heart Arrythmia: Premature Ventricular Contractions (PVC).
Heart Arrythmia: Premature Atrial Contractions (PAC).
Heart Arrythmia: Atrial Fibrillation.
Heart Arrythmia: Atrial Flutter.
Heart Arrythmia: Sick Sinus Syndrome.
Heart Arrythmia: Heart or Branch Block.
Heart Arrythmia: Wolff-Parkinson White Syndrome.
Heart Arrythmia: Bradycardia (Slow HR).
Heart Arrythmia: Tachycardia (Fast HR).
Heart Arrythmia: Long QT syndrome.
Heart Transplant.
Cardiac Stent.
Congestive Heart Failure.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Heart attack? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
STEMI.
NSTEMI.
Silent Heart Attack (CAS).
Unknown.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
High blood pressure (hypertension)? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Uncontrolled (Not taking medications).
Controlled (Taking medications as directed.).
Controlled by diet or other means.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Bacterial endocarditis? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Have experienced one episode.
Have had more than one episode.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Chest pain or angina? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Provoked (only with activity/anger/anxiety).
Spontaneous (with no activity/anger/anxiety).
Taking medication to control.
Have been hospitalized with chest pain.
Have shortness of breath with chest pain.
Chest pain frequency: Every Day.
Chest pain frequency: Once or several times a week.
Chest pain frequency: Once or several times a month.
Chest pain frequency: Less than once a month.
Chest pain frequency: Several times a year.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Anemia or abnormal bruising or bleeding? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Anemia: Pernicious Anemia.
Anemia: Iron Deficiency Anemia.
Anemia: Hemolytic Anemia.
Anemia: Sickle Cell Anemia.
Anemia: Thalassemia.
Anemia: Aplastic Anemia.
Anemia: Fanconi Anemia.
Anemia: Bone Marrow Anemia.
Leukemia.
Bruising.
Hemophilia A or B.
Factor Deficiency (II, V, VII, X, XII).
Von Willebrand’s Disease.
Blood disorders.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Do you have a pacemaker, defibrillator, or other artificial heart device? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Heart Valve Replacement (Porcine).
Heart Valve Replacement (Artificial).
Implantable Pacemaker: Single Chamber.
Implantable Pacemaker: Dual Chamber.
Implantable Pacemaker: Biventricular.
Implantable Defibrillator: Single Chamber.
Implantable Defibrillator: Dual Chamber.
Implantable Defibrillator: Biventricular.
Implantable Defibrillator: Subcutaneous.
Implantable Cardioverter Defibrillator.
Implantable Pacemaker/Defibrillator.
Artificial Heart.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Do you take blood thinners (e.g. Plavix, baby aspirin, Coumadin, warfarin)? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Aspirin.
Plavix (clopidogrel).
Coumadin (warfarin).
Xarelto (rivaroxaban).
Eliquis (apixaban).
Pradaxa (dabigatran).
Bevyxxa (betrixaban).
Savaysa (edoxaban).
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.