Bill 62 - BACPR Revalidation Exam

1 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.

2 ECG ETT: Y N Echocardiogram: Y N Angiogram: Y N. Full: Modified: Date: Date: Date: LV Function: Good Result: Result: +ve -ve Moderate Stage reached: METS: Poor Treatment planned: Reason for termination: Not Known OTHER MEDICAL HISTORY. No relevant medical history or please specify below: Stroke: Date: Details: Epilepsy: Since: Details: COPD/Asthma: Since: Details: Claudication: Since: Details: Musculoskeletal problems: Since: Details: Neuro problems: Date: Details: Other: Details: CHD RISK FACTORS (tick those applicable). Smoker Y N Ex High Cholesterol Physical Inactivity prior to Phase III Diabetes: Type 1 Type 2. Hypertension Stress affecting health Excess Alcohol FH of CVD BMI: Waist Circ: EARLY REHAB EXERCISE STATUS. Date started: Pre exercise BP final session: 130/86. Date completed: Pre exercise HR final session: 84bpm reg irreg Number of exercise sessions attended: 8 Prescribed training heart rate range: Mode: Circuit: or Gym: Achieved training heart rate range: 119. Total CV time ACHIEVED: 24 mins Average RPE: 12.

3 Mins per CV station: Approx METs achieved if known: Interval: AR time: Home exercises/activities: Walking and Static bike Continuous: Able to self pace: Y N. Adaptations/limitations: Frequency: x5 a week Intensity: moderate Cardiac symptoms during exercise: Y N. Time: 40 mins Type: walking 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: xxxxxx IMPORTANT NOTICE. At time of transfer this patient: is clinically stable concords with prescribed medication is not awaiting further cardiology investigations or treatment or is awaiting further follow up or treatment Please specify: Cardiac Rehabilitation Professional Signature: xxxxxxxx Date: Name: Tel: Contact Address: LONG TERM MANAGEMENT USE ONLY.

4 Risk Stratification Exercise Considerations: High Moderate Low Prescribed Training Heart Rate Range Karvonen: Personal Goals: To maintain and improve fitness and control blood sugars