Southern Cardio Group

Southern Cardio Group state of the art diagnostic cardiovascular testing

World Class Cardiovascular Diagnostic Testing Program

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Consent Questionnaire

Tell us a little about yourself

Full Name: *

First

Last

Today's Date

D.O.B

Age:

Height:

Gender:

Phone:

Email: *

Are you experiencing shortness of breath?

Yes
No
Ocassionally

Have you ever experience any chest pain?

Yes
No

Do you have difficulty breathing?

Yes
No

Have you ever experience any fluttering or pounding of your heart?

Yes
No

Have you ever experience any numbness or tingling ? If yes briefly explain

Check here if NO numbness or tingling

Details

Do you experience any dizziness, light headedness, or headaches?

Yes
No

Have you ever experience loss of consciousness ?

Yes
No

Do you have a cough ?

Yes
No

Do you have asthma ?

Yes
No

Do you have any known heart disease ?

Yes
No

Does anyone in your family have any known heart problems?

Yes
No

If yes briefly explain the problem or disease

Yes
No

Do you experience any pain in your legs or thighs ?

Yes
No

Southern Cardio Group

Charity for Athletes Corp

World Class Cardiovascular Diagnostic Testing Program

HOME
ABOUT
APPOINTMENTS
SPONSORSHIP
CONTACT
QUESTIONNAIRE

Southern Cardio Group state of the art diagnostic cardiovascular testing

(951) 496-4677

(954) 804-1864

info@southcardio.com

www.southcardio.com

Get involved

Charity for
Athletes Corp

111 W Harrison St # 415 CORONA, Ca 92878

Southern Cardio Group | California

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