Bill 62 - BACPR Revalidation Exam

BACPR Exercise Instructor Transfer Form Patients Name : bill Tel : Address : Age: 62 DOB: Emergency Contact Number: GP: Tel: Name: Surgery: Relationship: Address: CURRENT CARDIAC EVENT. Most Recent Cardiac Event: CABG Details: Complications: Date: CARDIAC HISTORY PRIOR TO ABOVE EVENT ANGINA/ARRHYTHMIA HISTORY. NO previous cardiac history Current Angina: Y N. Please tick those applicable below for all previous events giving dates where possible: Date of onset: STEMI: Date: Site: Details of angina: NSTEMI: Date: Unstable angina: Date: Triggers: Stable angina: Date: Relieved by rest or GTN: Y N. CABG: Date: Primary/Elective PCI: Date: Arrhythmias: Y N. Cardiac Arrest: Primary Secondary Date: Date of onset: Valve Repair/Replacement: Date : Details of arrhythmias: Heart Failure: Date: ICD/Pacemaker date fitted: NYHA classification: 1 2 3 4 Details/Settings: Ejection Fraction (if known): %. MEDICATION (PLEASE TICK THOSE CURRENTLY TAKEN). Aspirin: Clopidogrel/Prasugrel Diuretic: Lipid lowering:Statin Warfarin: Beta-blocker: Ivabradine: Anti - arrhythmic: Specify type: Alpha Blocker: Insulin: ACE Inhibitor: Angiotensin II Receptor Blocker: Nitrate: Other medications: GTN Spray/tablets: Frequency of use of GTN: Significant side effects causing problems: Calcium Channel Blocker: Name: Potassium Channel Activators: INVESTIGATIONS.

BACPR Exercise Instructor Transfer Form Patients Name : Bill Tel : Address : Age: 62 DOB: Emergency Contact Number: Name:

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