Application

Patient's Name

Date of Birth

Sex

MaleFemale

Weight

Height

Street Address

City

State

Country

Telephone Number

Email Address

Mother's Full Name

Father's Full Name

Patient Referred By

Patient's Siblings

Sibling #1

Name

Date of Birth

Sex

MaleFemale

Sibling #2

Name

Date of Birth

Sex

MaleFemale

Sibling #3

Name

Date of Birth

Sex

MaleFemale

Patient History

Vaccinations

Allergies

Medication Allergies

Previous Surgeries

Previous Hospitalizations

Current Medications

Cardiac Diagnosis

Other Illnesses and Diagnoses

Explain what kind of heart problems patient is currently presenting, in a detailed manner:

Family History

Do any BLOOD relatives (parent, brother, sister, or other blood relatives) have any of the following problems? Please state who is affected.

Heart Murmur

Hypertension (high blood pressure)

High Cholesterol Level

Death Due to Heart Disease

Financial Information

Father's Employer

Employer's Address

Employer's Telephone Number

Length of Employment

Job Title

Mother's Employer

Employer's Address

Employer's Telephone Number

Length of Employment

Job Title

Approximate Household Annual Income

Immigration Issues

Please indicate if patient and escort have the following required documents.

Patient

Escort

Passport

YesNo

Visa

YesNo

Permit

YesNo

None

YesNo

Other

YesNo

Requirements

Please submit the following in order for your application to proceed faster (if applicable):

Initial diagnostic evaluation
Medical progress notes (dated within six months of application)
Electrocardiaogram (ECG/EKG)
Echocardiogram (include video tape)
Chest X-RAY
Cardiac cath report(s) and if possible films