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Dr. Curtis
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Purpose of Today's Visit
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If "Other" selected, please indicate reason for visit:
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Since your last clinic visit, have you had any procedures, lab tests or need for medical care?
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If "yes" selected, please explain briefly:
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Are you experiencing?
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Chest Discomfort?
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Same, Better or Worse? (Choose One
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Breathlessness?
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Same, Better or Worse? (Choose One)
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Ankle Swelling?
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Same, Better or Worse? (Choose One)
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Cough?
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Same, Better or Worse? (Choose One)
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Light Headedness?
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Same, Better or Worse? (Choose One)
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Do you...?
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Smoke?
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If "yes", how often?
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Drink Alcohol?
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If "yes", how often?
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Drink Caffeine?
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If "yes", how often?
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Exercise?
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If "yes", how often?
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Follow a diet?
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If "yes", which type of diet?
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