UCL INSTITUTE OF HUMAN HEALTH AND PERFORMANCE
CENTRE FOR ALTITUDE SPACE AND EXTREME ENVIRONMENT MEDICINE
Cardiopulmonary Exercise Test Request Form
PATIENT DETAILS
Name
Address:
DOB
Hospital Number
Telephone HOME
number
MOB
REFERRING PHYSICIAN
Name
Name &
Address
for Reports
Department
Hospital
Contact
Telephone
number
Email
Name &
Address
for Invoice
Contact
Telephone
number
Email
REASON FOR TEST
Pre operative Evaluation
YES
NO
If no please specify reason for test:
Date of Surgery:
Surgical Procedure:
MEDICATIONS - Please give details of all medications
MOBILITY
ABLE TO WALK
WALKS WITH STICK
REQUIRES WHEEL CHAIR BUT HAS LIMITED MOBILITY
PERMANENTLY WHEEL CHAIR BOUND
ABLE TO CYCLE ON AN EXERCISE BIKE?
Please tick
YES
NO
First Floor, UCLH Podium, Clinic A, 235 Euston Road, London, NW1 2BU
UCL Division of Surgery and Interventional Science, 9th Floor, Royal Free Hospital, London, NW3 2QG
Email: ucl-tr.CPXref@nhs.net Website: http://www.ucl.ac.uk/anaesthesia/research/CPET
UCL INSTITUTE OF HUMAN HEALTH AND PERFORMANCE
CENTRE FOR ALTITUDE SPACE AND EXTREME ENVIRONMENT MEDICINE
MEDICAL HISTORY
CARDIOVASCULAR HISTORY
Please tick
Specific information AND date
MYOCARDIAL INFARCTION
YES
ANGINA
STABLE
CORONARY STENT (ANGIOPLASTY)
YES
NO
CABG
YES
NO
HYPERTENSION
YES
NO
CARDIAC FAILURE
YES
NO
PERIPHERAL VASCULAR DISEASE
YES
NO
STROKE - CVA OR TIA
YES
NO
DIABETES
YES
NO
VALVULAR HEART DISEASE
YES
NO
ARRYTHMIAS/RHYTHM DISORDERS
YES
NO
INHERITED HEART DISEASES
YES
NO
COPD
YES
NO
ASTHMA
YES
NO
PULMONARY EMBOLUS
YES
NO
PULMONARY HYPERTENSION
YES
NO
PULMONARY FIBROSIS
YES
NO
CURRENT SMOKER
YES
NO
PREVIOUS SMOKER
YES
NO
YES
NO
NO
UNSTABLE
RESPIRATORY HISTORY
MUSCULOSKELETAL
ARTHRITIS
ADDITIONAL DETAILS
Please include any additional relevant past medical history or investigations (e.g. chemotherapy,
previous surgeries, electrocardiogram, lung function, echocardiogram etc)
Please fill in the form– and do discuss via email with
Dr Rob Stephens (UCLH) or Dr Dan Martin (RFH) if you need clarification
ALL ENQUIRIES & FORMS TO ucl-tr.CPXref@nhs.net
First Floor, UCLH Podium, Clinic A, 235 Euston Road, London, NW1 2BU
UCL Division of Surgery and Interventional Science, 9th Floor, Royal Free Hospital, London, NW3 2QG
Email: ucl-tr.CPXref@nhs.net Website: http://www.ucl.ac.uk/anaesthesia/research/CPET