subject_line
Cardiac Questionnaire
Associated Therapists, Inc.
(714) 898-0362 Corporate Office
(714) 893-3267 Fax
www.associatedtherapists.com
Questions to assess the heart risk when starting medicines that can affect behavior:
Todays Date:
*
+
Client First Name:
*
Client Last Name:
*
Client's Age
Client's Gender
Male
Female
Your Name (if other than the client):
Relationship To Client:
*
Self
Spouse
Mother
Father
Other
Other
1. Have you or a family member ever experienced:
*
Yes
No
Don't Know
Dizziness (Pre-syncope)
Yes
No
Don't Know
Fainting (syncope)
Yes
No
Don't Know
If Yes to this question, use space below to give details:
2. Have you or a family member ever experienced:
*
Yes
No
Don't Know
Exercise related chest pain
Yes
No
Don't Know
Palpitations or arrhythmias (ususual, irregular, fast or strong heart beats)
Yes
No
Don't Know
Undue fatigue with exercise
Yes
No
Don't Know
Heart murmur
Yes
No
Don't Know
Hypertension (high blood pressure)
Yes
No
Don't Know
If Yes to this question, use space below to give details:
3. Do you or a family member have a history of:
*
Yes
No
Don't Know
Congenital heart problems
Yes
No
Don't Know
Prior heart surgery
Yes
No
Don't Know
If Yes to this question, use space below to give details:
4. Do you have a
family history
of sudden cardiac death before age 40?
*
Yes
No
Don't Know
If Yes to this question, use space below to give details:
5. Do you have a
family history
of any other conditions that may impact the heart such as Marfan syndrome or a cardiomyopathy?
*
Yes
No
Don't Know
If Yes to this question, use space below to give details:
6. Please list any other cardiac history or information below:
7. Please list all current medications, include dosage and reason for taking.
Powered by
Report abuse