PATIENTS DETAILS: REFERRERS DETAILS: Name: Name: Profession: Home Tel: Tel: Work Tel: Address: Mobile Tel: Permission to leave messages on voicemail Address: Email: Age: DOB: CARDIAC HISTORY NO previous cardiac history Current Angina Y N Please tick those applicable below for all previous events Date of onset: giving dates where possible: Details of angina: STEMI: Size Site: Date: Triggers NSTEMI: Date: Relieved by rest or GTN: Y N Unstable angina: Date: Arrhythmias Y N Devices Stable angina: Date: Date of onset: ICD fitted: CABG: Date: Details of arrhythmias: Pacemaker fitted: PCI: Primary Elective Date: Details/Settings: Cardiac Arrest: Primary Secondary Date: Valve Repair Replacement Date : Heart Failure: Date: NYHA classification: 1 2 3 4 MEDICATION Frequency of use of GTN INVESTIGATIONS ECG ETT: Y N B P Echocardiogram Y N Angiogram: Y N Date: EF : Date: Date: % Perfusion scan Y N Date: Myocardial CT Scan: Full Modified Pulse LV Function Good Y N Date: Diagnostic Moderate MRI Scan: Y N Date: Result: +ve -ve Poor Result/Treatment planned: Functional METS: Not Known OTHER MEDICAL HISTORY CHD RISK FACTORS (tick those applicable) non-smoker Smoker: Current smoker Ex-smoker Lifelong High Cholesterol Physical Inactivity Diabetes: Type 1 Type 2 Hypertension Anxiety Depression Excess Alcohol FH of CVD BMI: Waist Circ: IMPORTANT NOTICE - the patient:- PATIENT INFORMED CONSENT is clinically stable AND The patient agrees for the above information to be does not exhibit contraindications to exercise as per protocol (see Map of passed on to the Exercise Instructor.
PATIENTS DETAILS: REFERRERS DETAILS: Name: Home Tel: Work Tel: Mobile Tel: Permission to leave messages on voicemail Address: Email: Age: DOB: Name: Profession: Tel: Address: CARDIAC HISTORY NO previous cardiac history Please tick those applicable below for all previous events giving dates where possible: STEMI: Size Site: Date: NSTEMI: Date: Unstable angina: Date: Stable angina: Date: CABG: Date: PCI: Primary Elective Date: Cardiac Arrest: Primary Secondary Date: Valve Repair Replacement Date : Heart Failure: Date: NYHA classification: 1 2 3 4 Current Angina Y N Date of onset: Details of angina: Triggers Relieved by rest or GTN: Y N Arrhythmias Y N Date of onset: Details of arrhythmias: Devices ICD fitted: Pacemaker fitted: Details/Settings: MEDICATION Frequency of use of GTN INVESTIGATIONS ECG ETT: Y N Date: Full Modified Diagnostic Result: +ve -ve Functional METS: B P Pulse Echocardiogram Y N Date: EF : % LV Function Good Moderate Poor Not Known Angiogram: Y N Date: Perfusion scan Y N Date: Myocardial CT Scan: Y N Date: MRI Scan: Y N Date: Result/Treatment planned: OTHER MEDICAL HISTORY CHD RISK FACTORS (tick those applicable) Smoker: Current smoker Ex-smoker Lifelong non-smoker High Cholesterol Physical Inactivity Diabetes: Type 1 Type 2 Hypertension Anxiety Depression Excess Alcohol FH of CVD BMI: Waist Circ: IMPORTANT NOTICE - the patient:- PATIENT INFORMED CONSENT is clinically stable AND does not exhibit contraindications to exercise as per protocol (see Map of The patient agrees for the above information to be passed on to the Exercise Instructor.
Exercise%20for%20Cardiac%20Conditions%20%28BACPR%29%20Phase%20IV_0.docx