Intake form

Name *

Email address *

What is your age?

What is your gender?

What is your current health status?

Please select at least one option.

Healthy

Hypertension

Diabetes

High Cholesterol

Heart Disease

Do you have any known allergies?

What medications are you currently taking?

Have you experienced any heart-related symptoms?

Please select at least one option.

Chest Pain

Shortness of Breath

Palpitations

Dizziness

Fatigue

None

What is your preferred method of consultation?

Do you have a family history of heart disease?

What is your primary concern regarding your heart health?

Additional questions or comments

Please confirm that you are not a robot.

Cardiologista