Ch. Pervaiz Elahi Institute of Cardiology
Abdali Road, Multan,Punjab, Pakistan
Outpatient Cardiac Rehabilitation
Patient Information:
Date:
Patient Name: ____________________________________________ Date of Birth: __________________
Address: ________________________________________________________________________________
Phone: ________________________________________
Patient Registration#:_____________________________________
Diagnosis:
Sex: M
F
Post CABG
Post MI – within last year
- Ischemic cardiomyopathy
- Atherosclerosis of CABG- unspecified, w/ other angina pectoris
- Atherosclerosis of CABG- unspecified, w/ unspecified angina pectoris
- Atherosclerosis of CABG- w/o angina pectoris
- Atherosclerosis of native coronary artery transplanted heart- w/o angina
- STEMI L main coronary artery
- L anterior descending coronary artery other coronary artery – anterior wall
- R coronary artery
- other coronary artery – inferior wall
- circumflex coronary artery
- other sites
-unspecified sites
pectoris
- Other forms of chronic ischemic heart disease
Chronic ischemic heart disease, unspecified
Post Valve Repair or Replacement
Stable Angina Pectoris
- Prinzmetal Angina Pectoris
-Other forms of Angina
Pectoris
-Angina Pectoris unspecified
Secondary Diagnosis:
Hypertension
Hyperlipidemia
Obesity
Diabetes
Congestive Heart Failure
Social History:
Tobacco:
Type:
Current
Cigarette
Quit
Never
Packs per day:_____________
Huqqa
Medical History:
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