Download Cardiovascular Form - Hunterdon Healthcare

Center for Nutrition and Diabetes Management
Cardiovascular Risk Assessment
Name: _______________________________________________ Date: _____________________
Gender:  Male  Female  Other
DOB: _____________________
The most important things I want to learn/concerns I have:
 manage my cholesterol/lipids
 manage my weight
 plan meals
 use a PT/INR meter
 eat healthy/follow healthy diet
 portion control
 take better care of myself
 be consistent with exercise
 read food labels
 quit smoking
 avoid complications
 paying for supplies
 other: _________________________________________________________________________
Current Height: _______
Weight: _______
Self Monitoring Skills:
1. Do you check your weight regularly? ❒ No ❒ Yes How often? _________________________
2. What is your usual weight range? ________
3. Have you gained or lost weight recently? ❒ No ❒ Yes If so, how much? __________________
4. Do you record your results? ❒ No ❒ Yes
If yes, where: ___________________________
5. What do you do if your weight is higher or lower? ❒ Adjust medication dose _______________
❒ Call my doctor ❒ Nothing ❒ Adjust diet ❒ Other _____________________________
6. Do you check your blood pressure? ❒ Yes ❒ No
7. If yes h
Never
8. What is your usual blood pressure range? ____________________________________________
9. What do you do if your reading is high or low? ________________________________________
Learning Needs:
1. How do you like to learn? ❒ Reading ❒ Discussion
❒ Hands on training
❒ Role playing ❒ Internet
❒ Lecture
❒ Videos or DVDs
2. Education level? ❒ Grammar
❒ High school
❒ College
❒ Advanced degree(s)
3. Do you have and problems with hearing, vision or speech ? ❒ No
❒ Yes
Please explain: ______________________________________________________________
Nutrition:
1. Have you ever struggled with:
❒ Bulimia
2. What have you done about this? ____________________________________________________
3. Do you have any problems with: ❒ Gums
❒ Problems chewing
❒ Dentures
4. Who prepares your meals for you? ___________________________________________________
5. How many times a week do you eat away from home? __________________________________
❒ Fast food
❒ Restaurant ❒ Take out ❒ Other
6. Do you:
❒ Skip meals ❒ Nibble between meals ❒ Eat rapidly ❒ Have food cravings
❒ Use convenience foods
❒ Eat unplanned meals ❒ Other
7. What are your main beverages? _____________________________________________________
8. Are you currently on a special diet? ❒ No ❒ Yes If so, what? ___________________________
Exercise:
1. Do you exercise regularly? ❒ No ❒ Yes. What kind of exercise do you do? _____________
2. How often:
For how long? _______________________________
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edications: List all medications, vitamins, herbs and supplements you are taking:
Name
Dose
When Taken
Taking it as prescribed
Yes/No
Attach additional sheets if necessary.
If not taking medications as prescribed, what are your concerns? ____________________________
other (please explain): ______________________________________________________________
Do you take an aspirin daily? ❒ No ❒ Yes (dose:__________)
Have you had the following immunizations? ❒ Flu shot  Pneumonia (65 years and over)
 Zoster  T-dap  Meningococcal  Hepatitis A  Hepatitis B  Varicella MMR
Medicine Allergies: _______________________________________________________________
Food Allergies: ___________________________________________________________________
Family History: __________________________________________________________________
Your History:
❒ Heart problems
❒ High blood pressure (greater than 130/80 mmHg)
❒ High Stress
❒ High cholesterol and or lipids
 Diabetes  Thyroid
 Kidney disease
 Cancer
 Liver disease
 Lung disease
 Other ___________________________________________________________________
 Major Surgery ____________________________________________________________
Other Problems:
_________________________________________________________________________________
Cardiovascular History:
1. Have you ever had health education (by a nurse)? ❒ No ❒ Yes
If so when? ____________
2. Have you ever had nutrition education?
No
Yes
If so when __________________
3. Are there any religious or cultural factors that affect your health? ❒ No ❒ Yes
Explain:____________________________________________________________________
4. When were you diagnosed with your current condition? _________________________________
5. What is your understanding of your condition? ________________________________________
6. Have you had any recent hospital visits? ❒ Yes ❒ No
Please describe: _____________________________________________________________
7. Have you ever had chest pain, angina, and or a heart attack? ❒ Yes ❒ No
If yes, please explain _________________________________________________________
8. Have you had an exercise stress test? ❒ No
❒ Yes When? _______________________
9. Have you had an EKG?
❒ No
❒ Yes When? _______________________
10. Have you had a heart catherization? ________ If so, when and what was done? ______________
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_________________________________________________________________________________
11. Last appointment with health care provider for:
Last eye exam: __________
Last dental exam: ________
Last foot exam: _________
12. Do you carry a medication with you?
__________________________
❒ No
❒ Yes
13. Do you wear medical identification?
❒ No ❒ Yes
What?
Describe:________________________
Cardiovascular symptoms:
1. Have you had any of the following signs/symptoms?
❒ Chest pain ❒ Chest pressure
❒ Sweating
❒ Anxiety
❒ Dizziness
❒ Nausea
❒ Shortness of breath
❒ Pass out
❒ Skipping beats
❒ Weakness
❒ Uncontrolled blood pressure
❒ Fast heartbeat
❒ Palpations ❒ High blood sugars ❒ Leg ulcers ❒ Fluid in feet/legs
❒ Poor circulation
❒ Blood clots ________
3. Why do you get heart symptoms?
❒ Too much activity
❒ Unexplained
❒ Stress
❒ Other ___________________________________________________________________
4. How do you treat it?
❒ Nothing ❒ Rest
❒ Take medication _________________
❒ Call doctor
❒ Go to the Emergency Room
Anticoagulant Use:
1. Do you take Coumadin, Heparin, Lovenox, or other anti-coagulant medication? ❒ No ❒ Yes
If yes:
pill
Lovenox or Heparin injections
2. How long have you been on this medication? ________________________________________
3. Who prescribes it?_______________________________________________________________
4. If using injectable medication who gives the injection? __________________________________
5. Where do you inject?
❒ Arm
❒ Abdomen
❒ Thigh
6. Are you enrolled in the Community Safe Syringe Program?
7. Do you skip or adjust your anticoagulant medication?
8. If yes, why?
❒ Forget to take it
❒ Yes
❒ No
❒ Yes ❒ No
❒ Can’t afford it
❒ Ran out of it
❒ Follow physician orders for adjustment
9. Have your lab results been within the recommended range? ❒ Yes ❒ No
Alcohol/Nicotine/:
1. Do you drink alcohol? ❒ No
❒ Yes How much? _________________________________
How often? ________________________________________________________________
2. Do you use any nicotine products? ❒ Yes ❒ No If yes:
❒ Smoke cigarettes ❒ Chew tobacco ❒ cigars ❒pipe ❒Chew or dip tobacco
3. How much? ____________________________________________________________________
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4. If you stopped smoking/chewing, how long ago did you quit? ____________________________
5. If you have not stopped smoking/chewing, do you want to stop? ❒ Yes ❒ No
6. Do you currently use any drugs not prescribed for you? ❒ No
❒ Yes
❒ Marjijuana ❒Stimulants (cocaine, speed) ❒ sedatives (valium, xanax, ativan, etc)
❒ Heroin ❒ Methadone ❒ pain pills (Percocet, oxy, vicodin, etc) ❒ Other
If so, how often? ____________________________________________________________
Living and Working Situation:
1. With whom do you live? ❒ Alone ❒ Spouse ❒
Significant Other
2. Do you have support in your health management? If yes who: ___________________________
3. Are you currently employed? ❒ No ❒ Yes Type of Job: _____________________________
4. Are you are retired? ❒ No ❒ Yes What was your previous job? ______________________
5. Are you a student? ❒ No ❒ Yes Major? ________________________________________
6. Current stress level (0 none – 10 very high) ________
Sleep Problems:
Do you have any sleep problems? ❒ No ❒ Yes
If yes, do you have:
❒ Snoring
❒ Restless sleeping
❒ Periods of not breathing when sleeping
❒ Sleep deprivation due to snoring
❒ Feeling not rested and tired during the day
❒ Trouble getting to sleep/insomnia
❒ Sleep Apnea
❒ CPAP machine (use it?) ___________
Feelings and Concerns:
1. How do you feel about having cardiovascular disease?
❒ Okay ❒ Anxious
❒ Angry ❒ Overwhelmed
❒ Sad
❒ Afraid ❒ Depressed ❒ Unsure of what to do
❒ Other
Depression:
1. Have you recently felt down, depressed, hopeless or have little or no interest/pleasure in doing
things? ❒ Yes ❒ No
2. Are you being treated for depression?
❒ Yes
❒ No
Would you like a referral to speak to someone? __________________________________________
Pain Assessment:
1. Do you have a condition that causes pain? ❒ Yes
2. If yes, is it being managed effectively by your doctor? ❒ Yes ❒ No
Please explain: ______________________________________________________________
3. How does the pain affect your life? _________________________________________________
Women’s Health:
Menstrual Status:
Child bearing ❒ Perimenopausal
Questions you want answered:
________________________________________________________________________________
________________________________________________________________________________
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The following information is confidential. Thank you for taking the time to fill out this information.
_________________________________________________________________________________
Patient Signature
Date
_________________________________________________________________________________
Nurse Health Educator Signature
Date
_________________________________________________________________________________
Nutritionist Signature
Date
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