445 Caraway Drive, Poinciana, FL 34759
Office (407) 346-5361 Fax (877) 839-6499
Email – info@cardiocorps.com www.cardiocorps.com
Past Medical History (Include Surgical History)
Date Hospital Illness
Family History (Circle all that apply and list the relationship of family member.)
Heart Attack __________________ Heart Disease __________________ Stroke __________________
Diabetes __________________ Cancer __________________ Hypertension __________________
Pulmonary Fibrosis __________________ COPD __________________
Check ONLY IF YOU have any of the following symptoms.
_____ Loss of Hair _____ Hearing Difficulty _____ Weight loss (______ lbs)
_____ Shortness of Breath _____ Abdominal Pain _____ Weight gain (______ lbs)
_____ Arthritis _____ Black Tarry Stools _____ Palpitations
_____ Headache _____ Irregular Menses _____ Stroke
_____ Swelling in Neck _____ Impotence _____ Cough
_____ Double Vision _____ Blood in Urine _____ Dry Mouth
_____ Blind Spots _____ Frequent Urination _____ Difficulty Swallowing
_____ Cataracts _____ Change in Thickness of Stools _____ Asthma
_____ Pain in Eyes _____ Burning with Urination _____ Nose Bleeds
_____ Dizziness _____ Constipation _____ Frequent Thirst
_____ Lightheadedness _____ Sinus Problems _____ Sore Tongue
_____ Fainting Spells _____ Gum Infections _____ Chest Pain
_____ Dry Eyes _____ Heat Intolerance _____ Weakness/Numbness
_____ Pain in Ears _____ Cold Intolerance _____ Leg cramps when walking
_____ Roaring in Ears _____ Nervous Depression _____ Other ___________________
Plans/Recommendations
_____ Overnight Oximetry _____ Continue Prescribed Therapies _____ Other
_____ Follow up with PCP _____ Follow up home visit
Education Provided
_____ Overnight Oximetry Instructions _____ Nebulizer/Inhaler Usage _____ Breathing Techniques
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_____ Smoking Cessation Counseling _____ Disease Process
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Comments ______________________________________________________________________________________________
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FAX COMPLETED FORM TO CARDIOCORPS @ (877) 839 – 6499
445 Caraway Drive, Poinciana, FL 34759
Office (407) 346-5361 Fax (877) 839-6499
Email – info@cardiocorps.com www.cardiocorps.com
ASSIGNMENT OF BENEFITS
I, the undersigned, hereby authorize and release the IDTF designated above to bill my insurance and/or Medicare on my behalf
for the costs of this testing. Further, I authorize and request my insurance carrier to pay directly to the above-named IDTF, the
amount due to me under the terms of my policy, as a result of medical service rendered by that IDTF. I understand that I am
financially responsible for any claim denial, deductible or co-payment and agree to make payment to the IDTF at the time of
billing. I understand if I do not have insurance coverage or my insurance lapses I will be responsible for the full monetary
amount testing charges from the IDTF.
__________________________________________________ ___________________________
Patient Signature or Legal Representative (SIGNATURE REQUIRED) Date
_____________________________________________________________________________________________
If signed by Legal Representative, Print Name and Relationship Above
MEDICAL RECORDS RELEASE
I, the undersigned, authorize the IDTF above to release documents related to and including results of this test, from my medical
records file to the company/companies listed above as the “Home Medical Equipment Supplier (s). I also authorize the “Home
Medical Equipment Supplier(s)” to discuss with my physician any present or future treatment and/or follow-up services that
may be a result of this test.
__________________________________________________ ____________________________
Patient Signature or Legal Representative (Signature Optional) Date
_________________________________________________________________ ____________________________
Nurse Practitioner Signature Date
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FAX COMPLETED FORM TO CARDIOCORPS @ (877) 839 – 6499