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Company Other Secondary Insurance Company / Primary Insurance Company / / Facility Hospital Follow / Pharmacy Address / Pharmacy Phone / / MedicalCondition Hepatitis A / Arrhythmia / Ventricular Tachycardia / Congestive heart failure / ALLERGIES / Peripheral Vascular Disease / Valvular Heart Disease / Congenital Heart Disease / Hypertension / Cardiomyopathy / HIV / Chest pain / Peripheral Arterial Disease / Gastrointestinal Disease / Sudden Cardiac Death / Thyroid Disease / Herpes Zoster / Shingles / Arm Pain / Arthritis / Hematologic Disease / Shortness Of Breath / HPV / Rabies / Aortic Aneurysm / diphtheria / Dyslipidemia / Genitourinary Disease / tetanus / Heart Disease / Leg pain / Diabetes / Hepatitis C / Hepatitis B / Apnea / Hyperlipidemia / Pulmonary Disease / Polio / Syncope / Neurologic Disorder / Measles/Mumps/Rubella / GERD / Myocardial Infarction / Carotid Disease / Heart Failure / Disorder / Coronary artery disease / Atrial fibrillation / Dizziness / Influenza / Anemia / Atrial Flutter / Venticular Tachycardia / / MedicalTreatment Gastrointestinal Surgery / Cardiac Surgery / surgeries / Orthopedic Surgery / Cardiac Catheterization / Cardioversion / Vascular Surgery / Surgery / Abdominal Surgery / / Person Sister / Chicken Pox (Varicella) / Maternal Grandmother / Stress Level / Son / Paternal Grandmother / Uncle / Brother / Daughter / / Position General / / Product Penicillin / Doxycycline / Macrobid / Flomax / / Technology CAD / / SocialTag 
Today’s Date: ____________________ PATIENT VISIT/MEDICAL HISTORY – Cardiology Patient Name: ___________________________________________________ Date of Birth: ___________________