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BACPR Exercise Instructor Transfer Form Patients Name : Tel : Address : Age: DOB: Emergency Contact Number: GP: Tel: Name: Surgery: Relationship: Address: CURRENT CARDIAC EVENT Most Recent Cardiac Event: Details: Complications: Date: CARDIAC HISTORY PRIOR TO ABOVE EVENT ANGINA/ARRHYTHMIA HISTORY NO previous cardiac history Current Angina: Please tick those applicable below for all previous events giving dates where possible: STEMI: Size Site: Y N Date of onset: Date: Details of angina: NSTEMI: Date: Triggers: Unstable angina: Date: Relieved by rest or GTN: Stable angina: Date: CABG: Date: Y Arrhythmias Y N Devices N ICD fitted: PCI: Primary Elective Date: Date of onset: Pacemaker fitted: Cardiac Arrest: Primary Secondary Date: Details of arrhythmias: Details/Settings: Valve Repair Date : Replacement Heart Failure: Date: NYHA classification: 1 2 3 4 MEDICATION (PLEASE TICK THOSE CURRENTLY TAKEN) Aspirin Other anti-platelet Diuretic: Warfarin: Lipid lowering Beta-blocker Other oral anti-coagulant: Ivabradine Anti – arrhythmic Specify type: Alpha Blocker ACE Inhibitor Angiotensin II Receptor Blocker Insulin: Other medications: Nitrate GTN Spray/tablets Frequency of use of GTN: Calcium Channel Blocker Significant side effects causing problems: Name Potassium Channel Activators INVESTIGATIONS ECG ETT: Y N Echocardiogram Date: Modified LV Function Diagnostic Good Moderate +ve -ve Poor Functional METS: N Date: Full Result: Y Not Known Ejection Fraction : % 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 No relevant medical history Stroke: Date: Details: Epilepsy: Since: Details: COPD/Asthma: Since: Details: Claudication: Since: Details: Musculoskeletal problems: Since: Details: Neuro problems: Details: Date: Other: or please specify below: Details: CHD RISK FACTORS (tick those applicable) Smoker Y Diabetes: Type 1 N Anxiety Ex High Cholesterol Type 2 Hypertension Depression Physical Inactivity prior to Phase III FH of CVD BMI: Excess Alcohol Waist Circ: EARLY REHAB EXERCISE STATUS Date started: Pre exercise BP final session: Date completed: Pre exercise HR final session: Number of exercise sessions attended: Prescribed training heart rate range: Mode: Circuit: or reg Achieved training heart rate range: Gym Total CV time ACHIEVED: Average RPE: Mins per CV station: Approx METs achieved if known: Interval: AR time: Continuous: Able to self pace: Home exercises/activities: Y N Frequency: Adaptations/limitations: Cardiac symptoms during exercise: irreg Y N Time: Intensity: Type: please specify: PATIENT INFORMED CONSENT I agree for the above information to be passed on to the Exercise Instructor. I understand that I am responsible for monitoring my own responses during exercise and will inform the instructor of any new or unusual symptoms. I will inform the instructor of any changes in my medication and the results of any future investigations or treatment. Patient Signature: Date: IMPORTANT NOTICE At time of transfer this patient: is clinically stable concords with prescribed medication is not awaiting further cardiology investigations or treatment is awaiting further follow up or treatment. or Please specify: Cardiac Rehabilitation Professional Signature: Date: Name: Tel: Contact Address: