New Patient Questionnaire
For appointment with Cardiologist Dr. Annie Chou
First and Last Name: *
Your answer
Main heart concern: *
Your answer
Other heart concerns - check all that apply
Known drug allergies?
Family history of heart disease, rhythm problems, or unexpected deaths?
Do you smoke?
How much alcohol do you drink?
Do you currently use illicit drugs?
How many caffeinated beverages do you drink?
What do/did you do for work?
Your answer
Are you married/common-law?
How many children do you have?
Your answer
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