INTERVIEW AND ASSESSMENT
CARDIAC MEDICAL HISTORY
Date
 Myocardial Infarction
Location:
Thrombolytic Y or N
 CABG X
Grafts:
 PTCA _____________
 Stent X
Artery(s):
Artery(s):
Thrombolytic Y or N




Pacer / AICD
CHF
Arrhythmias
Complications
Type:
Type:
 Angina
Pattern:
CORONARY ANGIOGRAM
RCA:
Left Main :
LCX:
PDA:
LAD :
OM1:
Ramus:
D1/D2 :
OM2:
Test Date:
Left Ventricular Function:
EF%
ECHOCARDIOGRAM
Test Date:
Valvular Data:
Left Ventricular Function:
EF%
PULMONARY
 COPD
 CPAP
 O2 Use
 Other:
MUSCULO-SKELETAL
 Arthritis
Location:
 Knee L/R
Description:
 Shoulder L/R Description:
 Hip L/R Description:
 Back

OTHER MEDICAL HISTORY
PSYCHO-SOCIAL HISTORY
Present Occupation:
Former Occupation (if retired):
 Married  Single  Divorced  Widow/Widower
Retire Date:
Home Situation Spouse:
Significant Other _____________________Children:
Social Support: _________________________________________________________________________________________________
EATING HABITS
Previous Diet:
Current Diet:
Caffeinated Beverages:
Alcohol:
Dentures
YES/NO Attended Heart Class YES/ NO
EXERCISE HISTORY
Past Exercise:
Current Exercise:
Equipment at Home:
Home Exercise Assigned :

 Family Hx
 Diabetes
 Hypertension
RISK FACTOR EVALUATION
Description:
Type 1 or Type 2 Onset Date:
Monitor Glucose ? YES / NO
Treatment Type:
When:
Years:
 Hyperlipidemia Date:
Total:
 Smoking
Never / Date Quit:
 Stress
Description:
 Sedentary
Description:
 Obesity
Ht:
Wt:
HDL:
LDL:
Trig:
PPD:
Years :
Cessation Technique:
BMI:
Med:
(wt/(ht2))
RISK FACTOR MODIFICATION / PATIENT GOALS




 Improve stress management/incorporate balance in lifestyle
 Improve knowledge of CAD/lifestyle management
Establish an exercise program
Low cholesterol, low fat diet or Diabetic Diet
Stop Smoking
Patient’s Own Goal:
PLAN OF CARE





OPCR 3 times/week for a minimum of
visits.
Dietary Compliance
Home Exercise Program 30 - 45 minutes 4 - 6 times/week
Attend a smoking cessation program
Increase functional capacity to : 3 – 5 / 6 – 8 / 9 - 10 METs.




Develop a stress management program
Return to work or to a higher level of ADL’s
Attend Healing Hearts
Attend weekly OPCR Lifestyle Management Series
___________________________________________________
Interviewer
Date
St. Jude Medical Center Out Patient Cardiac Rehabilitation 101 E. Valencia Mesa Dr. Fullerton CA 92835