Patient Inquiry of CCMR   Name:   Gender:  Male  Female   Age:   Address:   Telephone#:   Fax#:   Mobil#:   E-mail:   What disease do you have?: Diabetes High Blood Pressure High Lipid Levels Chest Pain Other Heart Problem   When did you last see a docotor?:  within less than a month  between one to three months  more than three months ago   Which doctor do you most often see?:   Which hospital do you most often visit?:   How did you hear about CCMR program?: My doctor My family or friend Internet or newspaper   Why are you interested in join CCMR?:

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