Download BACPR Exercise Instructor Transfer Form Patients Name : Tel

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: