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AMS Coumadin Clinic
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Procedures & Testing
Echocardiography
Electrophysiology
Interventional Cardiology
Peripheral Vascular Disease
Miscellaneous Procedures
Conditions
Atrial Fibrillation
Aortic Stenosis, AVR, and TAVR
Bradycardia and Tachycardia
Peripheral Artery Disease
Preventive Cardiology & Lipid Management
Cardiac Rehab
Intensive Cardiac Rehab Center
PHYSICIANS
PA/NPs
LOCATIONS
Welsh Road – Main Office
Intensive Cardiac Rehab Center
North Wales
Abington
Get Directions
PATIENT INFORMATION
Forms
Contact Us
Menu
HOME
ABOUT US
Our Mission
AMS Coumadin Clinic
Patient Testimonials
Blog
SERVICES
Procedures & Testing
Echocardiography
Electrophysiology
Interventional Cardiology
Peripheral Vascular Disease
Miscellaneous Procedures
Conditions
Atrial Fibrillation
Aortic Stenosis, AVR, and TAVR
Bradycardia and Tachycardia
Peripheral Artery Disease
Preventive Cardiology & Lipid Management
Cardiac Rehab
Intensive Cardiac Rehab Center
PHYSICIANS
PA/NPs
LOCATIONS
Welsh Road – Main Office
Intensive Cardiac Rehab Center
North Wales
Abington
Get Directions
PATIENT INFORMATION
Forms
Contact Us
TELEMEDICINE
PATIENT PORTAL
PAY MY BILL
TELEMEDICINE
PAY MY BILL
PATIENT PORTAL
215-517-1000
LEAVE A REVIEW
CONTACT US
HOME
ABOUT US
Our Mission
AMS Coumadin Clinic
Patient Testimonials
Blog
SERVICES
Procedures & Testing
Echocardiography
Electrophysiology
Interventional Cardiology
Peripheral Vascular Disease
Miscellaneous Procedures
Conditions
Atrial Fibrillation
Aortic Stenosis, AVR, and TAVR
Bradycardia and Tachycardia
Peripheral Artery Disease
Preventive Cardiology & Lipid Management
Cardiac Rehab
Intensive Cardiac Rehab Center
PHYSICIANS
PA/NPs
LOCATIONS
Welsh Road – Main Office
Intensive Cardiac Rehab Center
North Wales
Abington
Get Directions
PATIENT INFORMATION
Forms
Contact Us
Menu
HOME
ABOUT US
Our Mission
AMS Coumadin Clinic
Patient Testimonials
Blog
SERVICES
Procedures & Testing
Echocardiography
Electrophysiology
Interventional Cardiology
Peripheral Vascular Disease
Miscellaneous Procedures
Conditions
Atrial Fibrillation
Aortic Stenosis, AVR, and TAVR
Bradycardia and Tachycardia
Peripheral Artery Disease
Preventive Cardiology & Lipid Management
Cardiac Rehab
Intensive Cardiac Rehab Center
PHYSICIANS
PA/NPs
LOCATIONS
Welsh Road – Main Office
Intensive Cardiac Rehab Center
North Wales
Abington
Get Directions
PATIENT INFORMATION
Forms
Contact Us
Health Questionnaire
"
*
" indicates required fields
Name
*
DOB
*
MM slash DD slash YYYY
Family Physician
Smoking History
Drug Allergeries (list medications and symptoms caused)
List current medications with dosage and frequency, include any vitamins & supplements:
Dosage
Frequency
Dosage
Frequency
Dosage
Frequency
Dosage
Frequency
Previous Surgeries
Family History
Father
Living
Deceased
Cause of Death
Illness
Mother
Living
Deceased
Cause of Death
Illness
Sibling
Living
Deceased
Cause of Death
Illness
Sibling
Living
Deceased
Cause of Death
Illness
Do you have any of the following?
Chest Pain
Yes, at rest
Yes, with exercise
No
If Yes, how long?
Shortness of breath
Yes
No
If Yes, how long?
Diabetes (or abnormal blood sugar)
Yes
No
If Yes, how long?
Increased or abnormal blood pressure
Yes
No
If Yes, how long?
Swelling of legs or feet
Yes
No
If Yes, how long?
Pain in calves when walking
Yes
No
If Yes, how long?
Heart Murmur
Yes
No
If Yes, how long?
History of Rheumatic Fever
Yes
No
If Yes, how long?
Palpitations (skipped heart beats or "rapid heart action")
Yes
No
If Yes, how long?
Passing Out or Black-Out Spells
Yes
No
If Yes, how long?
Have you ever had a "Heart Attack?"
Yes
No
If Yes, how long?
Have you ever been told you had an "Abnormal EKG?"
Yes
No
If Yes, how long?
History of Lung Disease
Yes
No
If Yes, how long?
History of Bleeding Disorder or Internal Bleeding
Yes
No
If Yes, how long?
Do you have an inserted device like and ICD, pacemaker or defibrillator?
Yes
No
If Yes, what brand?
St. Jude
Boston Scientific
Medtronic
Biotronic
Other (or unknown)
What single complaint bothers you the most?
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Comments
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