PATIENT INFORMATION AND FINANCIAL AGREEMENT (PLEASE PRINT)Patient Information and Financial Agreement • March 14th, 2014
Yes No Yes No Heart Disease: Congestive Heart Failure (CHF) Valvular Disease High Blood Pressure Stents Heart Attack Arrhythmia Atherosclerotic Disease Coronary Artery Bypass Angioplasty Angina Do you have a Pacemaker? Vascular Disease: Chronic Obstructive Pulmonary Disease (COPD) Respiratory Distress Syndrome Emphysema Recent Pneumonia Peripheral Artery Disease Stroke/TIA Blood Pressure Meds Chronic Bronchitis Diabetes Hypertension Asthma General Medical Conditions: Arthritis (rheumatoid/osteoarthritis) Osteoporosis Allergies Anxiety or Panic Disorders Neurological Disease (such as MSor Parkinson’s) Kidney, Bladder, Prostate orUrination Problems Headaches Previous Accidents GI Disease (ulcer, hernia, reflux,bowel, liver, gall bladder) Visual Impairment (cataracts,glaucoma, macular degeneration)
