Patient Forms

New Patient Intake Forms

Please complete these forms before your first appointment. Your information helps Dr. Nyange prepare the most comprehensive care for you.

All information is transmitted securely and kept strictly confidential in compliance with HIPAA regulations.

Personal Information

First Name *

Last Name *

Date of Birth *

Sex Assigned at Birth *

Email Address *

Phone Number *

Mailing Address

Emergency Contact Name & Phone

Reason for Visit

Primary Reason for Consultation *

Please describe your main symptoms or concerns *

When did these symptoms start?

Have you seen another cardiologist or specialist for this?

Medical History

Please describe any prior cardiac procedures or surgeries:

Family History (please list any first-degree relatives with heart disease, early heart attack, or sudden death):

Current Medications

Please list all current medications, doses, and frequency (include vitamins and supplements):

Known Drug Allergies

Lifestyle

Do you smoke or use tobacco?

Alcohol use

Exercise frequency

Diet description

For Women Only (skip if not applicable)

Menopausal status

Current hormone therapy?

Pregnancy history (complications such as preeclampsia, gestational diabetes, or preterm birth)

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