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Home
About
Conditions
Media
Forms
- New Patient Profile
- HOCATT Patient Form
Shop for your supplements
Location
- Whiting, NJ
Financing
Therapies/Services
Mobile Wellness Lounge

HOCATT Patient Form

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Please complete these pages as accurately and as completely as possible.
Name*
First Last
Date
MM slash DD slash YYYY

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Medical History and Screening Form
General Information
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact phone numbers
Birth Date
MM slash DD slash YYYY
Family Physician and/or Primary Health Care Provider:
Doctor/Others
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Signature
Marital Status
- Single
- Married
- Divorced
- Widowed
Sex
- Male
- Female
Occupation
Position
Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

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Present Medical History
Check those questions to which you answer yes (leave the others blank).
- Has a doctor ever said your blood pressure was too high?
- Do you ever have pain in your chest or heart?
- Are you often bothered by a thumping of the heart?
- Does your heart often race?
- Do you ever notice extra heartbeats or skipped beats?
- Are your ankles often badly swollen?
- Do cold hands or feet trouble you even in hot weather?
- Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary?
- Do you suffer from frequent cramps in your legs?
- Do you often have difficulty breathing?
- Do you get out of breath long before anyone else?
- Do you sometimes get out of breath when sitting still or sleeping?
- Has a doctor ever told you your cholestrol level was high?
- Has a doctor ever told you that you have an abdominal aortic aneurysm?
- Has a doctor ever told you that you have critical aortic stenosis?
Comments
Do you now have or have you recently experienced:
- Chronic, recurrent or morning cough?
- Episode of coughing up blood?
- Increased anxiety or depression?
- Problems with recurrent fatigue, trouble sleeping or increased irritability?
- Migraine or recurrent headaches?
- Swollen or painful knees or ankles?
- Swollen, stiff or painful joints?
- Pain in your legs after walking short distances?
- Foot problems?
- Back Problems?
- Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea?
- Significant vision or hearing problems?
- Recent change in a wart or a mole?
- Glaucoma or increased pressure in the eyes?
- Exposure to loud noises for long periods?
- An infection such as pneumonia accompanied by a fever?
- Significant unexplained weight loss?
- A fever, which can cause dehydration and rapid heartbeat?
- A deep vein thrombosis (blood clot)?
- A hernia that is causing symptoms?
- Foot or ankle sores that won't heal?
- Persistent pain or problems walking after you have fallen?
- Eye conditions such as bleeding in the retina or detached retina?
- Cataract or lens transplant?
- Laser treatment or other eye surgery?
Comments
Women only answer the following. Do you have:
- Significant childbirth - related problems?
- Urine loss when you cough, sneeze or laugh?
Comments
Are you on any type of hormone replacement therapy?
Men and Women answer the following:
List any prescription medications you are now talking:
List any self-prescribed medicatiions, dietary supplements, or vitamins you are now talking:
Date of last complete physical examination:
List any other medical or diagnostic test you have had in the past two years:
List hospitalizations, including dates of and reasons for hospitalization:
List any drug allergies:

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Past Medical History
Check those questions to which your answer is yes (leave others blank).
- Heart attack if so, how many years ago?
- Rheumatic Fever
- Heart Murmur
- Diseases of the arteries
- Varicose veins
- Arthritis of legs or arms
- Diabetes or abnormal blood-sugar tests Phlebitis
- (inflammation of a vein)
- Dizziness or fainting spells
- Epilepsy or seizures
- Stroke
- Diphtheria
- Scarlet Fever
- Infectious Mononucleosis
- Nervous or emotional problems
- Anemia
- Thyroid problems
- Pneumonia
- Bronchitis
- Asthma
- Abnormal chest X-ray
- Other lung disease
- Injuries to back, arms, legs or joint
- Broken bones
- Jaundice or gall bladder problems
Comments

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Other Heart Disease Risk Factors
Smoking
Have you ever smoked cigarettes, cigars or a pipe?
(If no, skin to diet section)
If you did or now smoke cigarettes, how many per day?
Age Started?
If you did or now smoke cigars, how many per day?
Age Started?
If you did or now smoke pipe, how many pipeful per day?
Age Started?
If you have stopped smoking, when was it?
If you now smoke, how long ago did you start?
Diet
What do you consider a good weight for yourself?
What is the most you have ever weighed (including when pregnant)?
How old were you?
My current weight is:
One year ago my weight was:
At age 21 my weight was:
Do you ever drink alcoholic beverages?
If yes, what is your approximate intake of these beverages?
Beer
- Daily
- Occasional
- Never
Wine
- Daily
- Occasional
- Never
Hard Liquor
- Daily
- Occasional
- Never
At any time in the past, were you a heavy drinker (consumption of six ounces of hard liquor per day or more)?
Comments
Comments
This field is for validation purposes and should be left unchanged.

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