1.1What is your preferred name?

Narrative response

1.2Who lives with you?

Select all that apply

• ☐I live alone
• ☐Spouse or partner
• ☐Children under age 18
• ☐Adult children
• ☐Parent(s) or in-law(s)
• ☐Other adult family
• ☐Roommates or unrelated adults
• ☐Assisted living or skilled nursing setting

1.3What is your current work or main daily activity?

If retired, describe what you used to do. If you are a caregiver for someone else, please say so.

Narrative response

1.4Who depends on you — emotionally, physically, or financially?

We ask because cardiac care plans look different when there are children at home, an aging parent you help, or a spouse whose health depends on yours.

Narrative response

1.5Do you have any physical or cognitive limitations we should know about?

Vision, hearing, memory, mobility, pain, dexterity, or anything else that affects how you give us information, take medication, or exercise.

Select all that apply

• ☐Vision impairment
• ☐Hearing impairment
• ☐Memory or cognitive concerns
• ☐Mobility limitations
• ☐Chronic pain affecting daily function
• ☐Limited hand dexterity
• ☐Speech or language difficulty
• ☐None of the above
• ☐Other (please describe)

1.6When you picture yourself truly well five years from now, what are you doing? Where are you? Who is with you?

There are no wrong answers. Dr. Silver wants to know what you are really working toward — not just a cholesterol number.

Narrative response

1.7What are you most worried about when it comes to your heart?

Narrative response

1.8Have you ever felt dismissed, rushed, or not truly listened to by a doctor?

If yes, please share what happened. You deserve to be heard. We want to start fresh.

Narrative response

1.9Is there a cultural, religious, or spiritual belief that shapes how you think about health, illness, medications, or end-of-life care?

Narrative response

2.1When did you first start thinking about your heart? What started it — a symptom, a test result, a family event, a doctor's comment, a scare?

Narrative response

2.2What is the single most important reason you sought out SilverHeart Medical Group and Dr. Silver specifically?

Narrative response

2.3If you had to say, what do you think is the most important thing going on with your heart right now?

Narrative response

2.4If you could get a clear answer to one heart question today, what would it be?

Narrative response

2.5Has anyone close to you recently had a heart event — heart attack, stroke, sudden death, bypass, stent, AFib diagnosis, or pacemaker?

If yes, describe what happened and how it affected your thinking about your own health.

Narrative response

Select all that apply

• ☐Coronary artery disease (clogged arteries), not requiring a procedure
• ☐Prior heart attack (myocardial infarction)
• ☐Prior stent(s) — angioplasty or PCI
• ☐Prior bypass surgery (CABG)
• ☐Stable angina (chest pain with exertion)
• ☐Unstable angina
• ☐Coronary spasm or microvascular disease (MINOCA or INOCA)
• ☐Abnormal stress test — but no formal CAD diagnosis
• ☐Abnormal coronary calcium score (CAC)

Select all that apply

• ☐High blood pressure (hypertension)
• ☐Resistant or hard-to-control high blood pressure
• ☐Low blood pressure causing symptoms
• ☐High cholesterol (hyperlipidemia)
• ☐Familial hypercholesterolemia (inherited high cholesterol)
• ☐High lipoprotein(a) — "Lp(a)"
• ☐High triglycerides

Select all that apply

• ☐Atrial fibrillation (AFib) — paroxysmal (comes and goes)
• ☐Atrial fibrillation (AFib) — persistent or permanent
• ☐Atrial flutter
• ☐Supraventricular tachycardia (SVT)
• ☐Ventricular tachycardia or fibrillation
• ☐Long QT syndrome or other inherited rhythm disorder
• ☐Heart block or bradycardia (slow heart rate)
• ☐Pacemaker in place
• ☐Implantable defibrillator (ICD) in place
• ☐Prior cardiac ablation procedure

Select all that apply

• ☐Heart failure with reduced ejection fraction (HFrEF, "weak heart muscle")
• ☐Heart failure with preserved ejection fraction (HFpEF, "stiff heart")
• ☐Hypertrophic cardiomyopathy (HCM)
• ☐Dilated cardiomyopathy
• ☐Restrictive or infiltrative cardiomyopathy (amyloid, sarcoid)
• ☐Prior myocarditis (heart inflammation)
• ☐Pericarditis (lining of the heart inflamed)
• ☐Pulmonary hypertension
• ☐Congenital heart disease (born with a heart condition)

Select all that apply

• ☐Aortic stenosis (tight aortic valve)
• ☐Aortic regurgitation (leaky aortic valve)
• ☐Mitral regurgitation (leaky mitral valve)
• ☐Mitral stenosis or mitral valve prolapse
• ☐Tricuspid regurgitation
• ☐Bicuspid aortic valve (born with 2 leaflets instead of 3)
• ☐Prior valve replacement or repair
• ☐Heart murmur — mentioned but never fully explained

Select all that apply

• ☐Stroke (any type)
• ☐Transient ischemic attack (TIA, "mini-stroke")
• ☐Carotid artery disease (narrowing in neck arteries)
• ☐Aortic aneurysm (thoracic or abdominal)
• ☐Aortic dissection history
• ☐Peripheral artery disease (PAD, leg artery blockages)
• ☐Claudication — leg pain with walking
• ☐Deep vein thrombosis (DVT)
• ☐Pulmonary embolism (PE)
• ☐Raynaud's phenomenon

3.1For each condition you checked above, please be ready to tell Dr. Silver the year of diagnosis, who diagnosed it, and its current status.

You do not need to write it here. We will cover each in your visit.

4.1Have you ever had chest discomfort of any kind — pressure, tightness, burning, squeezing, aching, or pain?

Select one

• ☐Never
• ☐Once or twice in my life
• ☐Occasionally
• ☐Often
• ☐Currently having these symptoms

4.2When it happens, where is the discomfort located?

Select all that apply

• ☐Center of the chest
• ☐Left side of the chest
• ☐Right side of the chest
• ☐Across the whole chest
• ☐Into the left arm
• ☐Into the right arm
• ☐Into both arms
• ☐Into the jaw or teeth
• ☐Into the neck or throat
• ☐Into the upper back or between the shoulder blades
• ☐Into the upper abdomen or stomach area

4.3What does it feel like?

Select all that apply

• ☐Pressure or heaviness
• ☐Tightness or squeezing
• ☐Burning
• ☐Sharp or stabbing
• ☐Aching or dull
• ☐Fullness, like an elephant on my chest
• ☐Like indigestion or heartburn
• ☐Like pulled muscle
• ☐Hard to describe

4.4What brings it on?

Select all that apply

• ☐Walking uphill or climbing stairs
• ☐Walking on flat ground at a fast pace
• ☐Lifting or carrying something heavy
• ☐Cold air
• ☐Heavy meals
• ☐Emotional stress or anger
• ☐Sexual activity
• ☐Lying down flat
• ☐Bending over
• ☐Coughing or taking a deep breath
• ☐Comes out of nowhere, even at rest
• ☐Wakes me from sleep

4.5How long does an episode usually last?

Select one

• ☐Seconds — comes and goes quickly
• ☐A few minutes
• ☐5–15 minutes
• ☐15–60 minutes
• ☐Hours
• ☐Unpredictable

4.6What makes it go away?

Select all that apply

• ☐Goes away on its own
• ☐Goes away with rest
• ☐Goes away with nitroglycerin
• ☐Goes away with antacids
• ☐Only goes away after hours or an ER visit

4.7What else happens during an episode?

Select all that apply

• ☐Shortness of breath
• ☐Sweating, especially cold sweat
• ☐Nausea or vomiting
• ☐Lightheadedness or near-fainting
• ☐Heart racing or pounding
• ☐Unusual tiredness all over
• ☐A sense of doom or feeling something is very wrong
• ☐Jaw, back, or arm pain without chest pain

4.8When was the most recent episode of chest discomfort?

Select one

• ☐Today or this week
• ☐Within the past month
• ☐Within the past 6 months
• ☐Within the past year
• ☐More than a year ago
• ☐Never had any

4.9Have you ever gone to an emergency room, urgent care, or been hospitalized for chest pain or a suspected heart attack?

If yes, please be ready to discuss when, where, and what happened.

Select one

• ☐No, never
• ☐Yes, once
• ☐Yes, more than once

5.1Have you ever been told you have high blood pressure?

Select one

• ☐No, never
• ☐Borderline or "pre-hypertension" only
• ☐Yes — on medication that controls it well
• ☐Yes — on medication but still not controlled
• ☐Yes — but not currently on medication
• ☐Yes — and I have tried and failed several medications

5.2About how old were you when you were first told your blood pressure was high?

Numeric entry (age in years)

5.3Do you check your blood pressure at home?

Select one

• ☐No, I do not own a cuff
• ☐I own one but rarely use it
• ☐Weekly
• ☐A few times a week
• ☐Every day, once
• ☐Every day, more than once
• ☐Only when I feel off

5.4If you check at home, what kind of cuff do you use?

Select one

• ☐Upper arm, automatic cuff
• ☐Wrist cuff
• ☐Smartwatch
• ☐Manual cuff
• ☐Not sure
• ☐I do not check at home

5.5What is a typical morning reading at home?

Your best estimate is fine. Example: 135 over 85.

Narrative response

5.6What is a typical evening reading at home?

Narrative response

5.7What is the highest reading you have ever seen?

Narrative response

5.8Does your blood pressure feel very different depending on the setting?

Select all that apply

• ☐Higher in the doctor's office than at home ("white coat")
• ☐Higher at home than at the doctor's office ("masked")
• ☐Very up and down throughout the day
• ☐Higher in the morning
• ☐Higher in the evening
• ☐Higher when I am stressed, as I would expect
• ☐No noticeable pattern

5.9Have you ever had symptoms you thought were from blood pressure?

Select all that apply

• ☐Headaches
• ☐Blurred vision
• ☐Nose bleeds
• ☐Chest discomfort
• ☐Shortness of breath
• ☐Dizziness when standing up
• ☐Fainting or near-fainting
• ☐None of these

5.10List every blood pressure medication you have ever taken, and what happened with each.

Be honest — "stopped because I felt tired" or "couldn't afford it" are as important as medical reasons.

Narrative response

6.1Have you ever been told your cholesterol was high?

Select one

• ☐No, never
• ☐Borderline
• ☐Yes — and I am on medication that works
• ☐Yes — on medication but still not at goal
• ☐Yes — not currently on medication
• ☐Yes — tried medication but could not tolerate it

6.2What do you remember about your most recent cholesterol numbers?

Total cholesterol, LDL, HDL, triglycerides, and Lp(a) if ever checked. Estimates are fine.

Narrative response

6.3Which cholesterol medications have you ever tried?

Select all that apply

• ☐Atorvastatin (Lipitor)
• ☐Rosuvastatin (Crestor)
• ☐Simvastatin (Zocor)
• ☐Pravastatin (Pravachol)
• ☐Lovastatin (Mevacor)
• ☐Pitavastatin (Livalo)
• ☐Ezetimibe (Zetia)
• ☐Bempedoic acid (Nexletol)
• ☐PCSK9 injection (Repatha, Praluent)
• ☐Inclisiran (Leqvio)
• ☐Icosapent ethyl (Vascepa)
• ☐Fibrate (gemfibrozil, fenofibrate)
• ☐Niacin
• ☐Red yeast rice or supplements
• ☐I have never taken a cholesterol medication

6.4If you had problems with a statin or other cholesterol medication, what happened?

Select all that apply

• ☐Muscle aches or soreness
• ☐Muscle weakness
• ☐Severe muscle breakdown (rhabdomyolysis)
• ☐Liver test abnormalities
• ☐Memory or cognitive changes
• ☐Fatigue
• ☐Gastrointestinal issues
• ☐New or worse blood sugar problems
• ☐Nothing — I tolerated it fine
• ☐Never tried one

6.5If you had muscle aches on a statin, please describe which muscles, when it started relative to the medication, and whether it improved after stopping.

Narrative response

6.6Was a blood test for muscle damage (creatine kinase / CK) checked when you had symptoms?

Select one

• ☐Yes — and it was normal
• ☐Yes — and it was elevated
• ☐No, it was not checked
• ☐I do not know
• ☐Not applicable

6.7Which of these cholesterol-related statements apply to you?

Select all that apply

• ☐I have heard I might have familial (inherited) high cholesterol
• ☐A blood relative had a heart attack before age 55 (men) or 65 (women)
• ☐I have been told I have high Lp(a)
• ☐I take fish oil or supplements for cholesterol
• ☐I avoid statins because of something I read or heard
• ☐I am open to newer injectable options if needed
• ☐I want to understand my real risk before deciding on any medication

7.1Have you ever felt your heart beat in a way you noticed — racing, pounding, skipping, fluttering, flip-flopping?

Select one

• ☐Never
• ☐Rarely — a few times in my life
• ☐A few times a year
• ☐Monthly
• ☐Weekly
• ☐Daily or more

7.2When it happens, what does it feel like?

Select all that apply

• ☐Pounding — I can feel every beat
• ☐Racing — very fast
• ☐Skipping — like a beat is missing
• ☐Fluttering — quivering
• ☐Irregular — no pattern at all
• ☐Thumping in the neck
• ☐Heavy sensation behind the breastbone

7.3How long does an episode usually last?

Select one

• ☐Seconds
• ☐Under a minute
• ☐A few minutes
• ☐15 to 60 minutes
• ☐Hours
• ☐More than a day
• ☐Unpredictable

7.4What brings it on?

Select all that apply

• ☐Caffeine
• ☐Alcohol
• ☐Stress or emotional upset
• ☐Lack of sleep
• ☐Physical activity
• ☐Lying down, especially on my left side
• ☐After a big meal
• ☐Dehydration
• ☐Out of nowhere
• ☐Around my menstrual cycle

7.5Have you ever worn a heart monitor (Holter, event monitor, patch, implanted loop, Apple Watch, KardiaMobile, Fitbit)?

Select all that apply

• ☐Never
• ☐Yes — Holter or short-term monitor
• ☐Yes — event monitor or patch
• ☐Yes — implanted loop recorder
• ☐Yes — Apple Watch or similar wearable
• ☐Yes — KardiaMobile / AliveCor

7.6Have you ever fainted or come close to fainting?

Select all that apply

• ☐Never
• ☐Near-fainting only — lightheaded, had to sit down
• ☐Once — classic fainting with warning
• ☐Multiple times — always with warning
• ☐Yes — without any warning
• ☐While exercising
• ☐While driving
• ☐After getting up from lying or sitting

7.7If you have atrial fibrillation (AFib), which apply?

Select all that apply

• ☐I do not have AFib
• ☐AFib comes and goes on its own (paroxysmal)
• ☐AFib is all the time now (persistent or permanent)
• ☐I have had a cardioversion (shock to reset my rhythm)
• ☐I have had an ablation
• ☐I am on a blood thinner
• ☐I was on a blood thinner but stopped
• ☐I am worried about bleeding on blood thinners
• ☐I have had a bleeding event on a blood thinner
• ☐I have a Watchman or other LAA closure device

7.8If you have AFib, what is most important for you to share about your experience with it?

Narrative response

8.1Compared to one year ago, how has your ability to walk and be active changed?

Select one

• ☐Better than a year ago
• ☐About the same
• ☐Slightly worse
• ☐Clearly worse
• ☐Much worse — I have had to give up activities

8.2How many flights of stairs can you climb without stopping to catch your breath?

Select one

• ☐More than 2 flights without stopping
• ☐2 flights
• ☐1 flight
• ☐Less than 1 flight
• ☐I avoid stairs altogether

8.3Do you get short of breath doing any of these?

Select all that apply

• ☐Walking on flat ground at a normal pace
• ☐Walking uphill or up stairs
• ☐Carrying groceries from the car
• ☐Making the bed or doing housework
• ☐Showering or dressing
• ☐Lying flat in bed (need to prop up on pillows)
• ☐Waking up suddenly at night feeling short of breath
• ☐Talking on the phone or during a full conversation
• ☐At rest, for no reason

8.4How many pillows do you sleep on?

Select one

• ☐One, flat
• ☐Two
• ☐Three or more
• ☐I sleep in a recliner or upright

8.5Do your feet, ankles, or legs swell?

Select all that apply

• ☐Never
• ☐Only at the end of a long day on my feet
• ☐Most evenings
• ☐Every day, most of the day
• ☐My shoes or socks leave deep marks
• ☐I can press a finger in and it leaves a dent

8.6Has your weight changed recently without trying?

Select all that apply

• ☐Up more than 5 pounds in a week
• ☐Up steadily over months
• ☐Down more than 5 pounds in a week
• ☐Down steadily over months
• ☐Stable

8.7Any of these other symptoms that might relate?

Select all that apply

• ☐New cough, especially lying down
• ☐Cough producing frothy or pink sputum
• ☐Feeling full in the belly
• ☐Loss of appetite
• ☐Nausea that seems unusual
• ☐Fatigue much worse than normal
• ☐Brain fog, slower thinking
• ☐None of these

9.1Has a doctor ever told you that you have a heart murmur, valve problem, or "something funny" on listening to your heart?

Select one

• ☐No
• ☐Yes, but I was told it was harmless or "innocent"
• ☐Yes — and I was told it needs follow-up
• ☐Yes — and I have had an echocardiogram for it
• ☐Yes — and I have been told it is significant or severe
• ☐I have had a valve replacement or repair

9.2If you have a known valve issue, what have you been told?

Narrative response

9.3Have you had any of these symptoms that can go with valve disease?

Select all that apply

• ☐Fainting or near-fainting with activity
• ☐Chest pain or pressure with activity
• ☐Shortness of breath getting worse
• ☐A feeling of pounding or fullness in the chest
• ☐Leg swelling
• ☐None of these

9.4Have you ever been told you have a bicuspid aortic valve, mitral valve prolapse, or a genetic connective tissue condition (Marfan, Loeys-Dietz, Ehlers-Danlos)?

Select all that apply

• ☐No
• ☐Bicuspid aortic valve
• ☐Mitral valve prolapse
• ☐Marfan syndrome
• ☐Loeys-Dietz syndrome
• ☐Ehlers-Danlos syndrome
• ☐Other connective tissue disorder

9.5Do you have any prosthetic (replaced) or repaired valves?

Select one

• ☐No
• ☐Yes — mechanical valve
• ☐Yes — tissue valve (surgical)
• ☐Yes — TAVR (transcatheter aortic valve replacement)
• ☐Yes — MitraClip or TEER
• ☐Yes — valve repair without replacement

9.6Do you take antibiotics before dental work for a valve condition?

Select one

• ☐Yes
• ☐No
• ☐Not sure — want to discuss

10.1Have you ever had a stroke or a TIA ("mini-stroke")?

Select one

• ☐No
• ☐Yes — stroke with lasting effects
• ☐Yes — stroke with full recovery
• ☐Yes — TIA (symptoms went away within 24 hours)
• ☐I had symptoms I suspect were one, but it was never formally diagnosed

10.2Have you had any of these symptoms that could have been a stroke or TIA, even briefly?

Select all that apply

• ☐Sudden weakness or numbness on one side
• ☐Sudden trouble speaking or understanding speech
• ☐Sudden vision loss in one eye ("curtain coming down")
• ☐Sudden double vision
• ☐Sudden severe headache unlike any other
• ☐Sudden trouble walking or loss of balance
• ☐Sudden confusion, even brief
• ☐None of these

10.3Do you get leg pain when walking that goes away with rest?

Select all that apply

• ☐No
• ☐Sometimes — in my calves
• ☐Sometimes — in my thighs or buttocks
• ☐Regularly — limits how far I can walk
• ☐Foot or toe pain at rest, especially at night
• ☐Wounds on feet or toes that won't heal

10.4Have you ever been told about a clot?

Select all that apply

• ☐Never had a clot
• ☐Deep vein thrombosis (DVT) — in the leg
• ☐Pulmonary embolism (PE) — clot in the lungs
• ☐Clot in the arm
• ☐Arterial clot (blocked an artery in leg, arm, or organ)

10.5Have you had imaging of your blood vessels — carotid ultrasound, CT/MR angiogram, or ankle-brachial index?

Select all that apply

• ☐No
• ☐Carotid ultrasound — normal
• ☐Carotid ultrasound — showed narrowing
• ☐CT or MR angiogram
• ☐Ankle-brachial index (ABI)
• ☐Abdominal aortic ultrasound

11.1Which of these are present in your blood relatives?

Select all that apply

• ☐Heart attack before age 55 in a male relative
• ☐Heart attack before age 65 in a female relative
• ☐Coronary bypass or stents in a relative
• ☐Stroke in a relative
• ☐Sudden death (died suddenly without a clear reason, at any age)
• ☐Death while exercising or playing sports
• ☐Atrial fibrillation
• ☐Pacemaker or defibrillator
• ☐High blood pressure
• ☐High cholesterol or familial hypercholesterolemia
• ☐High Lp(a)
• ☐Cardiomyopathy (enlarged or weak heart muscle)
• ☐Hypertrophic cardiomyopathy (HCM)
• ☐Long QT syndrome or other inherited rhythm condition
• ☐Aortic aneurysm or dissection
• ☐Marfan, Loeys-Dietz, or Ehlers-Danlos
• ☐Diabetes
• ☐Kidney disease
• ☐None of these — as far as I know
• ☐I don't know my family medical history

11.2Tell us about your father's health history.

Still living? Age now (or age at death). Heart or vascular conditions and age of diagnosis.

Narrative response

11.3Tell us about your mother's health history.

Narrative response

11.4Tell us about your siblings' health history.

Narrative response

11.5Tell us about your children's health history, if applicable.

Narrative response

11.6Tell us what you know about grandparents, aunts, uncles, and first cousins.

Patterns matter even when details are fuzzy. Just share what you know.

Narrative response

11.7Is there anyone in your family — close or distant — who died suddenly, especially young or while active?

Narrative response

11.8Have any family members had genetic testing for a heart condition? What did it show?

Narrative response

11.9Is there a country or ethnic background you identify with that might be relevant to cardiovascular risk?

Certain conditions — Lp(a) patterns, thalassemia, South Asian and African cardiovascular risk, Ashkenazi genetic variants — cluster by ancestry.

Narrative response

12.1Have you been told about your blood sugar?

Select one

• ☐Normal
• ☐Prediabetes or borderline
• ☐Type 2 diabetes — on oral medication only
• ☐Type 2 diabetes — on insulin
• ☐Type 1 diabetes
• ☐Gestational diabetes (during pregnancy)
• ☐Insulin resistance or metabolic syndrome
• ☐Not sure — want it checked

12.2If you have diabetes, how is it controlled?

Select one

• ☐Very well — A1c under 7
• ☐Reasonably — A1c 7 to 8
• ☐Struggling — A1c above 8
• ☐Not sure of my most recent A1c
• ☐Not applicable

12.3Are you on any of these newer medications?

Select all that apply

• ☐GLP-1 (Ozempic, Wegovy, Trulicity, Mounjaro, Zepbound)
• ☐SGLT2 inhibitor (Jardiance, Farxiga, Invokana)
• ☐Metformin
• ☐Insulin
• ☐Statin used partly for diabetes
• ☐None of these

12.4Any diabetes-related complications?

Select all that apply

• ☐Nerve pain or numbness (neuropathy)
• ☐Eye problems (retinopathy)
• ☐Kidney problems
• ☐Foot ulcers or slow healing wounds
• ☐None

12.5Have you been told about your kidneys or liver?

Select all that apply

• ☐Normal kidney function
• ☐Reduced kidney function (eGFR below 60)
• ☐On dialysis
• ☐Fatty liver (NAFLD or MASLD)
• ☐Hepatitis or other liver disease
• ☐High uric acid or gout history
• ☐None of the above

13.1What is your current weight?

Numeric entry (pounds)

13.2What is your height?

Numeric entry (feet and inches)

13.3What is your "usual" adult weight — the number you have been most of your adult life?

Numeric entry (pounds)

13.4What is the highest you have ever weighed as an adult, and at what age?

Narrative response

13.5What is the lowest you have weighed as an adult, and at what age?

Narrative response

13.6Over the past 10 years, how has your weight changed?

Select one

• ☐Stable — within 5 pounds
• ☐Slowly up — 10 to 20 pounds
• ☐Significantly up — more than 20 pounds
• ☐Yo-yo — up and down repeatedly
• ☐Slowly down
• ☐Recent unexplained loss

13.7Which weight loss approaches have you tried?

Select all that apply

• ☐Calorie counting
• ☐Low-carb or keto
• ☐Mediterranean
• ☐Intermittent fasting
• ☐Weight Watchers or similar program
• ☐Personal trainer or coach
• ☐Medical weight loss clinic
• ☐Prescription appetite medications (phentermine, Qsymia)
• ☐GLP-1 agonists (Ozempic, Wegovy, Mounjaro, Zepbound)
• ☐Bariatric surgery
• ☐Nothing formal — just tried to eat better

13.8What has worked for you in the past, and what has not? In your own words.

Narrative response

13.9Is there an emotional side to your relationship with food — stress eating, emotional eating, feeling judged, or a history of disordered eating?

This is a safe place to share. It changes what we recommend.

Narrative response

13.10Where do you tend to carry your weight?

Select one

• ☐Mostly in the abdomen ("apple shape")
• ☐Mostly in hips or thighs ("pear shape")
• ☐Evenly distributed

14.1Who buys the groceries and cooks in your home?

Narrative response

14.2How often do you eat out or order takeout?

Select one

• ☐Almost never — I cook nearly all meals
• ☐Once or twice a week
• ☐3 to 5 times a week
• ☐Most days
• ☐Every meal — I do not cook

14.3Describe a typical day of eating — breakfast, lunch, dinner, snacks, drinks. Be specific.

"Two eggs, toast with butter, black coffee" is more useful than "a healthy breakfast."

Narrative response

14.4How often do you eat these?

Select all that apply

• ☐Red meat 3+ times per week (beef, pork, lamb)
• ☐Processed meats regularly (bacon, sausage, deli, hot dogs)
• ☐Fried foods regularly
• ☐Fast food weekly or more
• ☐Sugary drinks daily (soda, sweet tea, juice, sports drinks)
• ☐Desserts or sweets daily
• ☐Salty snacks daily (chips, pretzels)
• ☐Whole fruits daily
• ☐Vegetables with most meals
• ☐Whole grains most days (brown rice, oats, whole wheat)
• ☐Fatty fish weekly (salmon, sardines, mackerel)
• ☐Nuts or seeds most days
• ☐Olive oil as primary cooking fat
• ☐Beans or lentils regularly

14.5How much do you watch salt and sodium?

Select one

• ☐Not at all
• ☐Sometimes
• ☐Carefully — I read labels
• ☐Very carefully — I have been told I must

14.6How often do you drink soda or other sugar-sweetened beverages?

This includes regular Coke, Pepsi, Dr Pepper, Mountain Dew, Sprite, root beer, sweet tea, lemonade, fruit punch, sports drinks (Gatorade, Powerade), energy drinks, and sweetened coffee or tea drinks.

Select one

• ☐Never
• ☐Less than once a week
• ☐1–2 times per week
• ☐3–6 times per week
• ☐Once a day
• ☐2–3 times a day
• ☐More than 3 times a day

14.7On a typical day that you drink soda or sweetened drinks, about how much do you drink in total?

One can = 12 oz. One bottle (small) = 16–20 oz. Big Gulp / large fountain = 32–44 oz. 2-liter bottle = 67 oz.

Select one

• ☐I don't drink them
• ☐Less than 12 oz (under one can)
• ☐12 oz (one can or small glass)
• ☐16–20 oz (one bottle)
• ☐24 oz (two cans)
• ☐32–44 oz (large fountain or Big Gulp)
• ☐More than 44 oz
• ☐More than one 2-liter bottle

14.8If you drink soda, is it usually regular, diet, or a mix?

Select one

• ☐I don't drink soda
• ☐Always regular (sugar-sweetened)
• ☐Mostly regular
• ☐Mix of regular and diet
• ☐Mostly diet or zero-sugar
• ☐Always diet or zero-sugar

14.9Caffeine — coffee, tea, energy drinks, pre-workout. Approximately how much and when?

Narrative response

14.10Any food allergies, intolerances, or cultural or religious dietary rules we should know?

Narrative response

14.11List every supplement you take regularly — vitamins, fish oil, protein powder, herbal products, anti-inflammatory blends, anything.

Some supplements interact with cardiac medications. Please be thorough.

Narrative response

15.1Do you exercise on purpose — planned physical activity beyond daily life?

Select one

• ☐Not currently
• ☐Less than once a week
• ☐1–2 days per week
• ☐3–4 days per week
• ☐5+ days per week

15.2What do you do?

Select all that apply

• ☐Walking
• ☐Running or jogging
• ☐Cycling — road
• ☐Cycling — stationary or Peloton
• ☐Swimming
• ☐Hiking
• ☐Pickleball, tennis, or racket sports
• ☐Golf — walking
• ☐Golf — cart
• ☐Yoga
• ☐Pilates
• ☐Strength training or weights
• ☐Group fitness (HIIT, CrossFit, SoulCycle, Orangetheory)
• ☐Dancing
• ☐Martial arts
• ☐Skiing or snowboarding
• ☐Rock climbing
• ☐Manual labor as part of my job
• ☐None

15.3In a typical week, roughly how many minutes of activity noticeably raises your heart rate and breathing?

Select one

• ☐0 minutes
• ☐Less than 30 minutes
• ☐30 to 75 minutes
• ☐75 to 150 minutes
• ☐150 to 300 minutes
• ☐More than 300 minutes

15.4Do you lift weights or do resistance training?

Select one

• ☐Never
• ☐Occasionally
• ☐1 to 2 times per week
• ☐3+ times per week

15.5What could you do a decade ago that you cannot do now? What was the turning point?

Narrative response

15.6What stops you from being more active?

Select all that apply

• ☐Joint or back pain
• ☐Shortness of breath
• ☐Chest discomfort
• ☐Fatigue
• ☐Fear of a heart event
• ☐Lack of time
• ☐Lack of motivation
• ☐No safe place to exercise
• ☐No access to gym or equipment
• ☐Don't know where to start
• ☐Bad experience with trainer or class
• ☐Nothing

15.7Do you wear a fitness tracker — Apple Watch, Garmin, Fitbit, Whoop, Oura? Which one?

Narrative response

16.1On a typical night, how many hours do you sleep?

Select one

• ☐Less than 5
• ☐5 to 6
• ☐6 to 7
• ☐7 to 8
• ☐More than 8
• ☐Varies wildly

16.2Do you snore?

Select one

• ☐No, or never been told
• ☐Quietly
• ☐Loudly enough to disturb a partner
• ☐Loudly enough to be heard from another room
• ☐Not sure — I live alone

16.3Has anyone told you that you stop breathing in your sleep, or gasp or choke awake?

Select one

• ☐No
• ☐Yes
• ☐Not sure

16.4Do you wake up feeling unrested, even after enough hours?

Select one

• ☐Never
• ☐Sometimes
• ☐Most days
• ☐Every day

16.5Do you fall asleep unintentionally during the day — watching TV, reading, driving?

Select one

• ☐Never
• ☐Sometimes watching TV
• ☐Often — daily
• ☐Even during conversations or driving

16.6Have you been tested for sleep apnea?

Select all that apply

• ☐No
• ☐Yes — home sleep test
• ☐Yes — in-lab polysomnogram
• ☐Diagnosed with obstructive sleep apnea
• ☐Using CPAP, BiPAP, or oral appliance regularly
• ☐Prescribed CPAP but don't use it

17.1Overall, how stressed do you feel right now in your life?

0–10 scale

• ☐0 — not stressed at all
• ☐5 — moderate stress
• ☐10 — overwhelmed

17.2What are the biggest sources of stress for you right now?

Select all that apply

• ☐Work or career
• ☐Finances
• ☐Marriage or partnership
• ☐Aging parents
• ☐Adult children
• ☐Young children
• ☐A loved one's health
• ☐My own health
• ☐Caregiving responsibilities
• ☐Grief or loss
• ☐Trauma, recent or old
• ☐Loneliness
• ☐Political or world events
• ☐Other

17.3In the past two weeks, how often have you had little interest or pleasure in things?

Select one

• ☐Not at all
• ☐Several days
• ☐More than half the days
• ☐Nearly every day

17.4In the past two weeks, how often have you felt down, depressed, or hopeless?

Select one

• ☐Not at all
• ☐Several days
• ☐More than half the days
• ☐Nearly every day

17.5In the past two weeks, how often have you felt nervous, anxious, or on edge?

Select one

• ☐Not at all
• ☐Several days
• ☐More than half the days
• ☐Nearly every day

17.6In the past two weeks, how often have you been unable to stop or control worrying?

Select one

• ☐Not at all
• ☐Several days
• ☐More than half the days
• ☐Nearly every day

17.7Do you currently see, or have you seen, a therapist, counselor, psychiatrist, or psychologist?

Select one

• ☐No, never
• ☐Yes, currently
• ☐Yes, in the past
• ☐I have been meaning to, but haven't
• ☐I would be open to it

17.8Are you on any medication for mood, anxiety, sleep, or attention?

Narrative response

17.9How do you handle stress — what works for you, what doesn't?

Narrative response

18.1Tobacco and nicotine

Select one

• ☐Never used tobacco or nicotine in any form
• ☐Former cigarette smoker — quit more than 1 year ago
• ☐Former cigarette smoker — quit within the last year
• ☐Current cigarette smoker
• ☐Current cigar, pipe, or hookah user
• ☐Current vape or e-cigarette user
• ☐Current smokeless tobacco user
• ☐Current nicotine pouch user (ZYN, On!, Velo, Rogue)

18.2If current or former smoker, approximately how many packs per day and for how many years?

Pack-years = packs per day multiplied by years smoked. Your estimate is fine.

Narrative response

18.3Alcohol — which best describes your use?

Select one

• ☐I don't drink alcohol
• ☐I used to drink — in recovery
• ☐Less than 1 drink per week
• ☐1 to 3 drinks per week
• ☐4 to 7 drinks per week (about 1 per day)
• ☐8 to 14 drinks per week
• ☐More than 14 drinks per week
• ☐Binge drinking occasionally (5+ drinks on one occasion for men, 4+ for women)

18.4Cannabis or marijuana

Select all that apply

• ☐Never used
• ☐Used in the past, not currently
• ☐Occasional use (less than weekly)
• ☐Weekly
• ☐Several days a week
• ☐Daily
• ☐Smoked flower
• ☐Vaped cannabis
• ☐Edibles
• ☐Tinctures or oils
• ☐Medical cannabis card

18.5Other substances — current or past use?

Stimulants in particular can cause heart attacks, arrhythmias, and cardiomyopathy in otherwise healthy people. Please be honest — we don't judge, and what you share is confidential.

Select all that apply

• ☐Cocaine
• ☐Methamphetamine or other stimulants
• ☐MDMA or ecstasy
• ☐Opioids not prescribed to you
• ☐Benzodiazepines not prescribed to you
• ☐Inhalants or poppers
• ☐Anabolic steroids or testosterone for performance
• ☐None of the above

19.1Please be prepared to provide or send us a current list of your prescription medications.

If you have a list in your phone, patient portal, or pill bottle labels, bring or send that. We will verify and enter it during your visit.

19.2Have you had a serious side effect from any medication? Describe what happened, what medication, and what you were told it was.

Narrative response

19.3Which of these apply to your relationship with medication?

Select all that apply

• ☐I generally prefer to avoid prescription medication when possible
• ☐I trust my doctors' recommendations and follow them
• ☐I research every medication before starting
• ☐I have felt pressured to take something I didn't want
• ☐I sometimes skip doses because of cost
• ☐I sometimes skip doses because I forget
• ☐I sometimes skip doses because I feel fine and question whether I need it
• ☐I have stopped medications without telling my doctor
• ☐I prefer natural or alternative approaches first
• ☐I take supplements in place of certain medications

19.4How do you prefer to take your medications?

Select all that apply

• ☐Once daily, ideally morning
• ☐Once daily, ideally evening
• ☐I don't mind multiple doses per day
• ☐I use a pill organizer
• ☐I use an app or reminder
• ☐A spouse or caregiver helps me
• ☐Mail-order pharmacy preferred
• ☐Local pharmacy preferred
• ☐90-day fills preferred

19.5Are there any medication classes you specifically want to avoid, based on past experience or belief?

Narrative response

19.6How well do you feel you currently understand your medication regimen — what each medication is, what dose, and when to take it?

Select one

• ☐1 — I don't really know what I take
• ☐2 — I know a few, but most are a blur
• ☐3 — I have a general sense
• ☐4 — I know most of them well
• ☐5 — I could recite every medication, dose, and timing

19.7How well do you feel you understand the reasoning behind each of your medications — why your doctors chose them and what they are meant to accomplish?

Select one

• ☐1 — I take them because I was told to
• ☐2 — I have a vague idea for one or two
• ☐3 — I have a rough idea of what each one is for
• ☐4 — I understand the reasoning behind most of them
• ☐5 — I understand the clinical reasoning for every one

19.8How well do you feel you understand the mechanism of your medications — how they actually work in your body?

Select one

• ☐1 — I have no idea how they work
• ☐2 — I have heard a few words but couldn't explain them
• ☐3 — I understand the basics for some of them
• ☐4 — I understand most of them at a working level
• ☐5 — I understand the pharmacology in detail

19.9How well do you feel you understand the basic physiology of your medical conditions — what is actually happening in your body that the medications are addressing?

Select one

• ☐1 — I just know the name of my condition
• ☐2 — I know a little, mostly from what I've been told in passing
• ☐3 — I understand the general picture
• ☐4 — I understand most of the underlying biology
• ☐5 — I understand the pathophysiology in detail

19.10How interested are you in understanding more about your medication regimen, the reasoning behind it, and how the medications work?

Select one

• ☐1 — Not interested; I trust my doctors and would rather focus on other things
• ☐2 — Mildly interested only when something changes
• ☐3 — Somewhat interested when it comes up
• ☐4 — Quite interested; I like knowing the details
• ☐5 — Very interested; I want to learn as much as I can

19.11How interested are you in understanding more about the basic physiology of your medical conditions?

Select one

• ☐1 — Not interested; I just want to feel better
• ☐2 — Mildly curious but not motivated to dig in
• ☐3 — Curious but not driven to learn more
• ☐4 — Quite interested; I read up when I have time
• ☐5 — Very interested; I want to understand what is happening in my body

19.12How confident are you that the possibility of harmful interactions between your medications, supplements, and conditions has been carefully considered by your care team up to this point?

This is one of the most important questions on the form. Your honest answer helps Dr. Silver know where to focus first.

Select one

• ☐1 — Not at all confident; I worry no one has truly looked at this
• ☐2 — A little confident; I assume someone has glanced at it
• ☐3 — Somewhat confident; my doctors seem aware but I am not sure
• ☐4 — Mostly confident; I think it has been reviewed reasonably well
• ☐5 — Completely confident; I have been thoroughly reviewed

19.13Have you ever experienced, or worried you experienced, a problem caused by an interaction between two or more of your medications, supplements, or conditions?

Select one

• ☐No, never
• ☐Yes, once
• ☐Yes, more than once
• ☐Suspected but never confirmed
• ☐Not sure

19.14Is there anything specific about your medications, conditions, or care plan that you wish someone would explain to you in a way that finally makes sense?

Narrative response

20.1Which of these tests have you had — to the best of your recollection?

Don't worry about getting this perfectly right. Check what you remember; we'll fill in the gaps together. If you're unsure whether a particular test was done, leave it unchecked and we'll discuss it.

Select all that apply

• ☐EKG or ECG
• ☐Echocardiogram (ultrasound of the heart)
• ☐Stress test — treadmill, no imaging
• ☐Stress echocardiogram
• ☐Nuclear stress test
• ☐Stress MRI
• ☐Cardiac CT angiogram
• ☐Coronary calcium score (CAC)
• ☐Cardiac MRI
• ☐Heart catheterization / angiogram
• ☐Holter monitor (24 to 48 hour)
• ☐Event monitor or patch monitor
• ☐Implanted loop recorder
• ☐Tilt table test
• ☐Electrophysiology (EP) study
• ☐Carotid ultrasound
• ☐Abdominal aortic ultrasound
• ☐Ankle-brachial index (ABI)
• ☐Lung function test (PFT or spirometry)
• ☐CT or MRI of the chest
• ☐None of the above

20.2For your most recent or most important cardiac test, what were you told the result was?

Narrative response

20.3If you have copies of any cardiac test results, can you send them or tell us where they were done so we can request them?

Narrative response

21.1Cardiac procedures you have had — to the best of your recollection

Don't worry about getting this perfectly right. Check what you remember; we'll work through the details together at your visit.

Select all that apply

• ☐Coronary angiogram (diagnostic only)
• ☐Coronary angioplasty or stent (PCI)
• ☐Coronary artery bypass surgery (CABG)
• ☐Valve repair
• ☐Valve replacement (surgical)
• ☐TAVR (transcatheter aortic valve replacement)
• ☐MitraClip / TEER
• ☐Watchman or LAA closure
• ☐Pacemaker
• ☐ICD (defibrillator)
• ☐Cardiac resynchronization (biventricular pacer / CRT)
• ☐Ablation (AFib, SVT, VT)
• ☐Cardioversion (shock to restart rhythm)
• ☐Pericardial window or pericardiocentesis
• ☐Aortic aneurysm repair
• ☐Carotid endarterectomy or stenting
• ☐Peripheral artery intervention
• ☐Heart transplant or LVAD
• ☐None of the above

21.2For each cardiac procedure you checked, please be ready to share the year, the hospital, and the doctor who performed it.

21.3Non-cardiac surgeries — appendix, gallbladder, joint replacement, back, hernia, cancer surgery, etc.

Narrative response

21.4Hospitalizations in the last 5 years — cardiac or non-cardiac. Include ER visits that led to overnight observation.

Narrative response

22.1Do you have any medication allergies?

Narrative response

22.2Have you reacted to iodine contrast (used for CT scans and heart catheterizations)?

Select one

• ☐No
• ☐Yes — mild (hives, itching)
• ☐Yes — moderate (needed treatment)
• ☐Yes — severe (anaphylaxis, hospitalization)
• ☐Not sure

22.3Have you reacted to MRI contrast (gadolinium)?

Select one

• ☐No
• ☐Yes
• ☐Not sure

22.4Other allergies — foods, latex, bees, environmental, or pets?

Narrative response

23.1For patients who have been pregnant — which apply?

If you have never been pregnant, skip to question 23.3.

Select all that apply

• ☐Preeclampsia or toxemia in any pregnancy
• ☐HELLP syndrome
• ☐Gestational hypertension
• ☐Gestational diabetes
• ☐Preterm delivery (before 37 weeks)
• ☐Low birthweight baby
• ☐Peripartum cardiomyopathy (heart weakness around pregnancy)
• ☐Recurrent miscarriages
• ☐Infertility treatment history
• ☐None of the above

23.2Approximately how many pregnancies and live births?

Narrative response

23.3Menstrual and menopausal history

Select one

• ☐Still having regular periods
• ☐Irregular periods or perimenopause
• ☐Menopause — natural
• ☐Surgical menopause (ovaries removed)
• ☐Early menopause (before age 45)
• ☐Not applicable

23.4Any of these gynecologic conditions?

Select all that apply

• ☐PCOS (polycystic ovary syndrome)
• ☐Endometriosis
• ☐Fibroids
• ☐Prior hysterectomy
• ☐None of the above

23.5Hormone therapy — current or past use?

Select all that apply

• ☐Current birth control pills or hormonal IUD
• ☐Past oral contraceptive use
• ☐Current hormone replacement therapy (estrogen, progesterone)
• ☐Past hormone replacement therapy
• ☐Testosterone therapy
• ☐Thyroid hormone replacement
• ☐None

23.6For men — any history of erectile dysfunction, low testosterone, or related concerns?

Erectile dysfunction is often the first warning sign of cardiovascular disease in men — sometimes years before a heart event. This is a crucial question, not an embarrassing one.

Select one

• ☐No concerns
• ☐Some concerns — open to discussing
• ☐Diagnosed with ED, on treatment
• ☐Diagnosed with low testosterone, on treatment
• ☐Not applicable

23.7Thyroid history

Select all that apply

• ☐No thyroid issues
• ☐Hypothyroid — on medication
• ☐Hyperthyroid (current or past)
• ☐Thyroid nodules
• ☐Prior thyroid surgery or ablation

24.1Who are the people whose opinions you want at the table when a significant cardiac decision needs to be made?

Spouse, adult children, parents, siblings, close friends, clergy, others. Be ready to share names, relationships, and contact information.

Narrative response

24.2How do you want those people to be involved?

Select all that apply

• ☐I want them copied on communications and test results
• ☐I want them in the room (or on the video call) for important visits
• ☐I want them to hear Dr. Silver's recommendations directly, not filtered through me
• ☐I want to talk to Dr. Silver alone first, then bring them in
• ☐I want them only for logistical support, not medical decisions
• ☐I prefer to make decisions privately

24.3Do you have a designated healthcare decision-maker who could speak for you if you were unable?

Select one

• ☐I have a formal healthcare proxy or power of attorney — I will send a copy
• ☐I have one informally but no paperwork
• ☐I don't have one — would like help setting this up
• ☐I don't want to name one

24.4If your family disagrees with each other about your care, whose voice do you most want heard?

Select one

• ☐Mine — the final call is always mine, full stop
• ☐Mine, but I want the group to weigh in first
• ☐My designated decision-maker's voice should take priority
• ☐We decide together — everyone gets a say, then I choose
• ☐Dr. Silver's recommendation should resolve family disagreements
• ☐I haven't thought this through — I want to discuss it

24.5If your family disagrees with Dr. Silver's medical recommendation, how do you want that handled?

Select all that apply

• ☐I want Dr. Silver to advocate clearly for what he believes is medically right, even if my family pushes back
• ☐I want Dr. Silver to present all the options neutrally and let us work it out
• ☐I want a family meeting with Dr. Silver to talk it through together
• ☐I want a second opinion sought quickly in those situations
• ☐I want Dr. Silver to side with my stated wishes, even if my family disagrees
• ☐I want Dr. Silver to side with my family, even if I initially disagree

24.6Have there been past medical decisions in your family where you felt pressured, overruled, or unheard? What happened?

Narrative response

24.7When you think about major cardiac decisions — surgery, aggressive medications, devices — where do you sit on this spectrum?

Select one

• ☐1 — Do everything possible to live as long as possible
• ☐2 — Lean toward aggressive intervention, but with limits
• ☐3 — Somewhere in the middle — balance length and quality
• ☐4 — Lean toward quality of life, but willing to intervene when it matters
• ☐5 — Prioritize quality of life over length of life

24.8When you weigh risk vs. benefit of an intervention, what matters most to you?

Select all that apply

• ☐Living as long as possible
• ☐Preventing a major event (heart attack, stroke)
• ☐Maintaining independence — being able to live on my own
• ☐Staying active — walking, traveling, doing what I love
• ☐Avoiding hospitals and procedures whenever possible
• ☐Avoiding medication side effects
• ☐Avoiding cognitive decline
• ☐Being present for a specific event (wedding, grandchild, milestone)
• ☐Financial cost and burden on family
• ☐Not being a burden to others

24.9Are there specific outcomes you consider worse than death?

Select all that apply

• ☐Being on a breathing machine long-term
• ☐Being unable to recognize my family
• ☐Being dependent on others for basic care
• ☐Severe chronic pain
• ☐Loss of independence
• ☐I have not thought about this
• ☐I prefer not to answer now — but will discuss

24.10Advance directives and code status

Select all that apply

• ☐I have an advance directive — I will send a copy
• ☐I have a POLST or MOLST form
• ☐I am clearly DNR / DNI (do not resuscitate or intubate)
• ☐I want full resuscitation efforts
• ☐I want Dr. Silver's help thinking this through
• ☐This is too much to think about right now — we can revisit later

24.11Is there anything your family does not know about your values or wishes that Dr. Silver should know — in case they need to advocate for you?

Narrative response

24.12Tell us about a medical decision you have previously made that you feel good about. What made it feel right?

Narrative response

25.1What insurance or coverage do you have?

Select all that apply

• ☐Medicare (Traditional)
• ☐Medicare Advantage
• ☐Commercial or employer insurance
• ☐Supplemental or Medigap
• ☐Medicaid
• ☐VA or TRICARE
• ☐Self-pay / no coverage

25.2Have medication costs ever caused you to skip, split, or delay filling a prescription?

Select one

• ☐No
• ☐Occasionally
• ☐Regularly
• ☐Yes, but I don't like admitting it

25.3Practical barriers to care

Select all that apply

• ☐Transportation to appointments can be difficult
• ☐I live far from major hospitals
• ☐I travel frequently and need care coordinated across locations
• ☐I split time between two residences
• ☐Work makes daytime appointments difficult
• ☐Caregiving responsibilities limit when I can come in
• ☐Internet or video visit access is limited
• ☐I prefer in-person care over telemedicine
• ☐I prefer telemedicine when possible
• ☐None of these

25.4If you split time between two or more residences, please share where and the typical schedule.

Narrative response

25.5Your local care team — please be ready to share names, locations, and contact information for:

You do not need to write these out here. We will enter them during your visit.

Select all that apply

• ☐Primary care physician
• ☐Endocrinologist
• ☐Nephrologist
• ☐Pulmonologist or sleep specialist
• ☐Other specialist
• ☐Pharmacy

26.1What do you most want Dr. Silver to understand about you before your first visit?

Narrative response

26.2Is there anything you have been hesitant to say to a doctor before, that you feel ready to say now?

Narrative response

26.3What would make this relationship with SilverHeart Medical Group feel like a success, a year from now?

Narrative response