Houston Cardiovascular Associates Houston Cardiovascular Associates

Our Health Library information does not replace the advice of a doctor. Please be advised that this information is made available to assist our patients to learn more about their health. Our providers may not see and/or treat all topics found herein.

First Appointment

Overview

Complete this form if you are seeing this health professional for the first time. Although you may have to complete a similar form when you arrive at the office, completing this form will help you organize your thoughts and provide more complete information.

Complete Section 2 at the end of your appointment if you have a health problem that needs treatment.

Section 1: Current health and health history

Why did I make this appointment?

Am I having any symptoms? Describe them. If pain is one of my symptoms, include where it is, how it feels, and how severe it is.

Has there been a recent change in my normal routine (for example, sleeping, eating, recent death of a loved one, divorce)?

Questions for women

Questions for women to ask

Am I pregnant? Yes____ No____ When was my last menstrual period? _____________

At what age did my menstrual cycles begin? _________ My cycles are: Regular____ Irregular ____

When was my last mammogram? ___________ If the results were abnormal, explain:

When was my last Pap smear? __________ If the results were abnormal, explain:

When was I last screened for colon cancer (if I am older than 50)? ________________ If the results were abnormal, explain:


Questions for men

Questions for men to ask

When was my last prostate examination (if I am older than 50 and younger than 75)? ______________ If the results were abnormal, explain:


When was I last screened for colon cancer (if I am over age 50)? _____________ If the results were abnormal, explain:


Immunization history

Immunizations

Immunization

Date last received

Influenza

Pneumococcal

Tetanus (Td and Tdap)

Hepatitis B

Shingles

Other

Health history

Health problems
Fill in your current health problems, such as poor eyesight or diabetes, and the name of the health professional you see for each problem.

Health problem

Health professional




Hospitalizations
Fill in the information for each time you have been in the hospital. Include any surgeries you have had on an outpatient basis.

When was I there? (date or year)

Why was I in the hospital?

Who was my doctor?

What hospital was I in?














Allergies
Fill in the following information if you have allergies to medicines or other substances.

Medicine or other substance

My reaction




Family history
List family members (parents, brothers, sisters, grandparents) who have or had the following major conditions.

Health condition

Relative (parent, brother, sister, grandparent)

Age, if living

Age at death

Comments

Heart problems



Kidney disease



Lung disease



Depression or other major mental health condition



Diabetes



Breast cancer



Colon cancer



Other cancer or inherited disease



Tobacco and alcohol use

Product (cigarettes, pipe, cigars, or chewing tobacco)

How much am I using now, or how much did I use before I quit?(for example, 1 pack of cigarettes a day or 1 cigar about once a week)

How long has it been since I quit?










Physical exercise

What type of exercise do I do? (for example, walking, jogging, stretching)

How frequently do I exercise? (for example, 3 times a week)

How long do I exercise each time?(for example, 10 minutes, 30 minutes)




Personal preferences

Do I have any cultural, religious, or personal beliefs that may affect my treatment options? Describe them briefly:


What other concerns do I have?


Stop here. By the end of your appointment, make sure you have answers to the questions in Section 2 if you need treatment for a health problem as the result of this visit.

Section 2: Treatment for this health problem and next steps

What is the diagnosis?

What does it mean in plain English?

What might happen next?

Do I need a medicine? Yes ___ No ___ If yes, fill in the following information.

Medicines

Name of medicine

How much and how often to take it

What to watch for




Do I need surgery or another treatment? Yes ___ No ___ If yes, fill in the following information.

Surgery or another treatment

Name of treatment

Who will do it

Where it will be done and what to do to prepare for it

What are the risks and benefits of medicine, surgery, or other treatment? Fill in the following information about the treatment your health professional recommends for this condition.

What are the chances that the treatment will work?

What are the risks associated with the treatment?

What might happen if I delay or avoid treatment?

How soon will I see results of the treatment?

What other treatment options are available?

Do I need a medical test or X-ray? Yes ___ No ___ If yes, fill in the following information.

What is the name of the test?

Will the test results change the treatment? If yes, explain:

How do I get the test results?

What home treatment can I do?
Ask the following questions about what you can do to help treat your condition.

Questions to ask

What do I need to change? How?

  • Eating:
  • Sleeping:
  • Exercise:
  • Other:

What home treatment do I need to add? (for example, using a humidifier)


Do I have concerns about being able to carry out my part of the treatment? Yes ___ No ___ If yes, discuss them with your health professional now.

Where can I get more information about this problem or the treatment?

How soon do I need to make a decision about getting a test or starting treatment?

What signs and symptoms should I watch for?

When should I call to report signs and symptoms?

Is there a chance that someone else in my family might get the same condition?

When should I contact my health professional?
Fill in the appropriate box below with the date and time, if needed.

Check here if no contact is needed.

Call for test results or to report how I am doing:

Return for an appointment:

____

Date: ____

Time: ____

Date: ____

Time: ____

Reminder

Bring to your appointment all your medicines or a list of all the medicines you are taking.

Credits

Current as of: April 30, 2024

Author: Ignite Healthwise, LLC Staff
Clinical Review Board
All Ignite Healthwise, LLC education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

Current as of: April 30, 2024

Author: Ignite Healthwise, LLC Staff

Clinical Review Board
All Ignite Healthwise, LLC education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

Dear patient

I am excited to announce that I will be relocating my practice to Houston Methodist DeBakey Cardiology Associates. Starting November 4, 2024, my new address will be:

5115 Fannin, Suite 801
Houston, TX 77004

Please note that my phone number and fax number will also change to the following:
24-Hour Telephone: 713-441-1100
Fax: 713-790-2643
Clinical Support Telephone (M-F, 8-5): 713-441-3515

I am excited about caring for you in my new office and hope you will make the transition with me. I will also continue to refill your medications as I have in the past. To assist, please provide your pharmacy with my new contact information.

Please consider checking your prescription refills to verify that you have enough medication on hand to last you until your next visit. Please note that your medical records will remain at my former office until you authorize their transfer. If you choose for me to continue providing your medical care, please complete and sign the enclosed “Authorization for Release of Medical Records” form and fax it to 713-790-2643. Once we receive your authorization, we will be happy to process the request for you.

Thank you for entrusting me with your medical care. My new team and I are dedicated to making this transition as seamless as possible. For help scheduling an appointment and transitioning your care, please call my new office number above.

I look forward to continuing your care at my new location.

Sincerely,
Gopi A. Shah, MD

Dear patient

Dr. Albert Raizner, Dr. Michael Raizner, and Dr. Mohamed El-Beheary are excited to announce that our practice, Interventional Cardiology Associates, will merge with Houston Cardiovascular Associates on November 1, 2024.

Our new offices are similarly located in Houston, near the Texas Medical Center and in Sugar Land. Our in-hospital care will continue at Houston Methodist Hospital in the Texas Medical Center and Houston Methodist Sugar Land Hospital. Importantly, our new offices expand our services with state-of-the-art equipment and amenities. Our core values will always be, as they began over 40 years ago when Dr. Albert Raizner founded ICA:

Integrity – Compassion – Accountability

Our new address and contact information are:

Your medical records are confidential and remain available at our new locations. We consider it a privilege to serve as your cardiologists and look forward to your continuing with us. However, should you desire to transfer to another physician, you may request a copy of your records by contacting us at our new addresses and phone numbers listed above.

We thank you for your trust and loyalty. As always, we will continue to be here to take care of you. Please do not hesitate to contact us if you have any questions or concerns.

Sincerely,

Dr. Albert Raizner,
Dr. Michael Raizner,
Dr. Mohamed El-Beheary