| PATIENT: _____________________________________________________ SOCIAL SECURITY NUMBER: ___________________________________ DATE OF BIRTH: _______________________________________________ |
| 1. | Date you first examined this patient: _________________ | |||||||||||
| Date of most recent exam: _______________ Height: ________ Weight: ________ | 2. | Current Diagnosis: |
3. | Regarding Hypertension: |
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| a) | Please list the last three blood pressure readings with dates: ______________________ Date: __________________ ______________________ Date: __________________ ______________________ Date: __________________ | |||||||||||
b) | Is there idication of End Organ Damage because of Hypertension in any of the following organs? (Please indicate)
| 4. | Congestive Heart Failure YES _______ NO _______ |
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| a) | Failure Demonstrated by (Please indicate) Pulmonary Edema ________________________ Peripheral Edema ________________________ Hepatomegaly ___________________________ Jugular Vein Distension ____________________ Dyspnea _______________________________ | |||||||||||
| b) | Cause of Congestive Heart Failure (Please indicate) Hypertension ___________________________ Arteriosclerosis _________________________ Myocardial Infraction ____________________ Rheumatic Fever ________________________ Other ________________________________ | |||||||||||
| c) | Has the patient had a Myocardial Infraction? Yes ______ No ______ Date(s) __________________________ Basis for Diagnosis: Peak Enzyme Value: CPK ______ LDH ______ SGOT ______ Demonstrated by Serial EKG's: Yes ______ No ______ | |||||||||||
5. | Ischemic Heart Disease: Yes ______ No ______ | |||||||||||
| a. | Basis for Diagnosis (Please indicate): | |||||||||||
| 1) Treadmill Exercise Test: | ||||||||||||
| 2) Transmural Myocardial Infraction: | ||||||||||||
| 3) ECG with Ischemic Configuration: | ||||||||||||
| 4) "Double" Master Two-Step Test: | ||||||||||||
| 5) Second or Third Degree Heart Block: | ||||||||||||
| 6) Angiographic Evidence: | ||||||||||||
| 7) ECG with Left Bundle Branch Block: | ||||||||||||
| 8) Left Vertricular Ejection Fraction of Less than 30%: | ||||||||||||
| 9) Angina: | ||||||||||||
| 6. | Other Heart Disease (Please indicate): Myocardiopathies: Rheumatic Heart Disease: Other: | |||||||||||
| 7. | Aneurysm of Aorta or Major Branches? Yes ______ No ______ Date Diagnosised: _________________________ | |||||||||||
8. | Chest Pain: Yes ______ No ______ Description (Please indicate all that apply): | |||||||||||
| a) QUALITY | b) LOCATION | c) PRECIPITAT- ING FACTOR | d) DURATION | e) FREQUENCY |
| ___ Crushing | ___ Precordial | ___ Walking | ___ More than an hour | ___ Constant |
| ___ Burning | ___ Substernal | ___ Emotional Upset | ___ All day | ___ Hourly |
| ___ Rhythmic | ___ Inframam- mary | ___ Eating | ___ Less than 15 mins. | ___ Daily # of times |
| ___ Stabbing | ___ Parasternal | ___ Working (physical) | ___ 1/2 hour | ___ per day |
| ___ Dull Ache | ___ Left Chest | ___ Exposure to cold | ___ Few seconds | ___ Weekly # of times |
| ___ Squeezing | ___ Air | |||
| ___ Shooting | ___ Climbing | |||
| ___ Soreness | ___ Lifting/carrying | |||
| ___ Varies with Respiration | ___ Other | |||
| ___ Sharp | ||||
| ___ Heaviness | ||||
| ___ Pressure- like | ||||
| ___ Radiating | ||||
| ___ Other |
9) | Cardiomegaly: Yes ______ No ______. Description: |
| 10) | Angiogram: Yes ______ No ______ Date(s) ______ |
| Findings: Left Main Coronary Artery: | |
| (Please indicate degree of narrowing or obstruction): | |
| Proximal Arteries: | |
| Other: | |
| 11) | Cardiac Surgery: Yes _____ No _____ a) If no, is surgery recommended? Yes _____ No ______ b) If yes, what type? Date: |
| 12) | Is this patient's Cardiac Impairment controlled with Medication? Yes ______ No _______ |
13) | Does the patient's Cardiac Impairment restrict any daily activities? Yes ______ No ______ How, and which activities? |
14) | Other Comments: |
| Date Report Completed: | ______________________________ |
| Signature of Physician: | ______________________________ |
| Physician Name: | ______________________________ |
| Address: | ______________________________ |
| Telephone: | ______________________________ |
| Specialty: | ______________________________ |