BSA - CT TAVR Patient Form

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* 1. Who is your primary doctor?

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* 2. Patient Information

Last Name

First Name

Middle Initial

Social Security Number

Date of birth (MM/DD/YYYY)

Age

Gender (Male or Female)

Marital Status (Married, Divorced, Widowed, or Single)

Mailing Address

City

State

Zip

Home Phone Number

Work Phone Number

Other Phone Number

Email Address

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* 3. Emergency Contact's Information

Last Name

First Name

Middle Initial

Home Phone Number

Work Phone Number

Other Phone Number

Relationship to Patient

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* 4. Responsible Party’s Information (if different from patient)

Last Name

First Name

Middle Initial

Social Security Number

Date of birth (MM/DD/YYYY)

Age

Gender (Male or Female)

Marital Status (Married, Divorced, Widowed, or Single)

Mailing Address

City

State

Zip

Home Phone Number

Work Phone Number

Other Phone Number

Employer

Relationship to Patient

If your illness is related to an on the job injury please complete an insurance information form.

Medical History

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* 5. Do you regularly smoke? If so, do you smoke cigarettes, a pipe, or cigars? How much? How long?

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* 6. Please list your previous surgeries and dates:

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* 7. If you have any of the following conditions, please check next to them:

High blood pressure

Kidney trouble

Diabetes

Lung trouble

Heart trouble

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* 8. Do you take any form of blood thinner?

Yes

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* 9. Please provide the reason for today’s visit

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* 10. Please list all drug allergies

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* 11. Sign (patient or guardian) below if this statement is true:

I authorize the release of any medical information necessary to process a claim in my behalf and request payment of any insurance benefits to myself or BSA Amarillo Surgical group.

Patient Medications

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* 12. Update, date and initial at each visit

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* 13. Please provide the Patient ID

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* 14. Please list all medication allergies including:
a.     Medication
b.     Dosage (Medication strength)
c.     Frequency (How often do you take this medication?)
d.     No Change (or comments)
e.     Date
f.      Initial

Kansas City Cardiomyopathy Questionnaire (KCCQ-12)

In the following questions refer to your heart failure and how it may affect your life. Please read and complete the following questions. There are no right or wrong answers. Please provide the answer that best applies to you.

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* 15. Heart Failure affects different people in different ways. Some feel shortness of breath while others feel fatigue. Please indicate how much you are limited by heart failure (shortness of breath or fatigue) in your ability to do the following activities over the past 2 weeks.

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* 16. When showering/bathing, how do you feel?

Extremely limited

Quite a bit limited

Moderately limited

Slightly limited

Not at all limited

Limited for other reasons

Did not do the activity

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* 17. When walking 1 block on level ground how do you feel?

Extremely limited

Quite a bit limited

Moderately limited

Slightly limited

Not at all limited

Limited for other reasons

Did not do the activity

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* 18. When hurrying or jogging (as if to catch a bus) how do you feel?

Extremely limited

Quite a bit limited

Moderately limited

Slightly limited

Not at all limited

Limited for other reasons

Did not do the activity

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* 19. Over the past 2 weeks, how many times did you have swelling in your feet, ankles or legs when you woke up in the morning?

Every morning

3 or more times per week but not every day

1-2 times per week

Less than once a week

Never over the past 2 weeks?

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* 20. Over the past 2 weeks, on average, how many times has fatigue limited your ability to do what you wanted?

All of the time

Several times per day

At least once a day

3 or more times per week but not every day

1-2 times per week

Less than once a week

Never over the past 2 weeks

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* 21. Over the past 2 weeks, on average, how many times has shortness of breath limited your ability to do what you wanted?

All of the time

Several times per day

At least once a day

3 or more times per week but not every day

1-2 times per week

Less than once a week

Never over the past 2 weeks?

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* 22. Over the past 2 weeks, on average, how many times have you been forced to sleep sitting up in a chair or with at least 3 pillows to prop you up because shortness of breath?

Every night

3 or more times per week but not every day

1-2 times per week

Less than once a week

Never over the past 2 weeks

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* 23. Over the past 2 weeks, how much has your heart failure limited your enjoyment of life? Which one of the following apply:

It has extremely limited my enjoyment of life

It has limited my enjoyment of life quite a bit

It has moderately limited my enjoyment of life

It has slightly limited my enjoyment of life

It has not limited my enjoyment of life at all

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* 24. If you had to spend the rest of your life with your heart failure the way it is right now, how would you feel?

Not satisfied at all

Mostly dissatisfied

Somewhat satisfied

Mostly satisfied

Completely satisfied

How much does your heart failure affect your lifestyle? Please indicate how your heart failure may have limited your participation in the following activities over the past 2 weeks.

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* 25. When performing hobbies or recreational activities how do you feel?

Severely limited

Limited quite a bit

Moderately limited

Slightly limited

Did not limit at all

Does not apply

Did not do for other reasons

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* 26. When working or doing household chores do you feel

Severely limited

Limited quite a bit

Moderately limited

Slightly limited

Did not limit at all

Does not apply

Did not do for other reasons

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* 27. When visiting family or friends out of your home, how do you feel?

Severely limited

Limited quite a bit

Moderately limited

Slightly limited

Did not limit at all

Does not apply

Did not do for other reasons

Review of Systems:

Constitutional
Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

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* 28. Chills

Yes

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* 29. Fatigue

Yes

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* 30. Fever

Yes

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* 31. Night sweats

Yes

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* 32. Weight Gain

Yes

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* 33. Weight Loss

Yes

Head/ Eyes/ Ears/ Throat

Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

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* 34. Hearing loss

Yes

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* 35. Sore throat

Yes

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* 36. Visual changes

Yes

Respiratory

Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

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* 37. Chronic cough

Yes

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* 38. Cough

Yes

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* 39. Known TB Exposure

Yes

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* 40. Shortness of Breath

Yes

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* 41. Wheezing

Yes

Cardiovascular

Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

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* 42. Chest pain

Yes

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* 43. Claudication (Leg Cramps)

Yes

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* 44. Palpitations

Yes

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* 45. Edema (Swelling of feet, ankles or legs)

Yes

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* 46. Dyspnea (Shortness of breath with exertion)

Yes

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* 47. Orthopnea (Difficulty breathing when lying flat)

Yes

Vascular

Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

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* 48. DVT (Blood clots in legs)

Yes

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* 49. Phlebitis (Varicose Veins)

Yes

Gastrointestinal

Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

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* 50. Abdominal pain

Yes

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* 51. Blood in stools

Yes

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* 52. Change in stools

Yes

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* 53. Constipation

Yes

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* 54. Diarrhea

Yes

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* 55. Heartburn

Yes

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* 56. Loss of appetite

Yes

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* 57. Vomiting

Yes

Reproductive (FEMALE ONLY)

Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

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* 58. Breast discharge

Yes

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* 59. Breast lump

Yes

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* 60. Irregular Menses

Yes

Genitourinary

Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

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* 61. Dysuria (Difficulty Urinating)

Yes

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* 62. Hematuria (Blood in Urine)

Yes

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* 63. Frequent Urination

Yes

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* 64. Urinary Incontinence

Yes

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* 65. Urinary Retention

Yes

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* 66. Nocturia (Awakening to Urinate)

Yes

Metabolic/Endocrine

Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

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* 67. Brittle nails

Yes

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* 68. Cold intolerance

Yes

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* 69. Changes

Yes

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* 70. Heat Intolerance

Yes

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* 71. Polydipsia (Excessive Thirst)

Yes

Neurological

Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

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* 72. Extremity numbness

Yes

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* 73. Extremity weakness

Yes

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* 74. Headache

Yes

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* 75. Memory Loss

Yes

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* 76. Seizures

Yes

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* 77. Tremors

Yes

Psychiatric

Please provide a yes next to each symptom below if you experience it, or please provide a no next to each symptom if you do not experience it.

BSA - CT TAVR Patient Form

Question Title

* 1. Who is your primary doctor?

Question Title

* 2. Patient Information

Question Title

* 3. Emergency Contact's Information

Question Title

* 4. Responsible Party’s Information (if different from patient)

Question Title

* 5. Do you regularly smoke? If so, do you smoke cigarettes, a pipe, or cigars? How much? How long?

Question Title

* 6. Please list your previous surgeries and dates:

Question Title

* 7. If you have any of the following conditions, please check next to them:

Question Title

* 8. Do you take any form of blood thinner?

Question Title

* 9. Please provide the reason for today’s visit

Question Title

* 10. Please list all drug allergies

Question Title

* 11. Sign (patient or guardian) below if this statement is true:I authorize the release of any medical information necessary to process a claim in my behalf and request payment of any insurance benefits to myself or BSA Amarillo Surgical group.

Question Title

* 12. Update, date and initial at each visit

Question Title

* 13. Please provide the Patient ID

Question Title

* 14. Please list all medication allergies including:a. Medicationb. Dosage (Medication strength)c. Frequency (How often do you take this medication?)d. No Change (or comments)e. Datef. Initial

Question Title

* 15. Heart Failure affects different people in different ways. Some feel shortness of breath while others feel fatigue. Please indicate how much you are limited by heart failure (shortness of breath or fatigue) in your ability to do the following activities over the past 2 weeks.

Question Title

* 16. When showering/bathing, how do you feel?

Question Title

* 17. When walking 1 block on level ground how do you feel?

Question Title

* 18. When hurrying or jogging (as if to catch a bus) how do you feel?

Question Title

* 19. Over the past 2 weeks, how many times did you have swelling in your feet, ankles or legs when you woke up in the morning?

Question Title

* 20. Over the past 2 weeks, on average, how many times has fatigue limited your ability to do what you wanted?

Question Title

* 21. Over the past 2 weeks, on average, how many times has shortness of breath limited your ability to do what you wanted?

Question Title

* 22. Over the past 2 weeks, on average, how many times have you been forced to sleep sitting up in a chair or with at least 3 pillows to prop you up because shortness of breath?

Question Title

* 23. Over the past 2 weeks, how much has your heart failure limited your enjoyment of life? Which one of the following apply:

Question Title

* 24. If you had to spend the rest of your life with your heart failure the way it is right now, how would you feel?

Question Title

* 25. When performing hobbies or recreational activities how do you feel?

Question Title

* 26. When working or doing household chores do you feel

Question Title

* 27. When visiting family or friends out of your home, how do you feel?

Question Title

* 28. Chills

Question Title

* 29. Fatigue

Question Title

* 30. Fever

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* 31. Night sweats

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* 32. Weight Gain

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* 33. Weight Loss

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* 34. Hearing loss

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* 35. Sore throat

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* 36. Visual changes

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* 37. Chronic cough

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* 38. Cough

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* 39. Known TB Exposure

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* 11. Sign (patient or guardian) below if this statement is true:

I authorize the release of any medical information necessary to process a claim in my behalf and request payment of any insurance benefits to myself or BSA Amarillo Surgical group.

* 14. Please list all medication allergies including:
a. Medication
b. Dosage (Medication strength)
c. Frequency (How often do you take this medication?)
d. No Change (or comments)
e. Date
f. Initial