Cardiac Catheterization Lab Assessment Form
Complete this assessment to help prepare for a cardiac catheterization procedure and review readiness, history, medications, and safety considerations.
Patient and Referral Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Details
Referring Provider Name
*
Cardiologist Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Assessment (Optional)
Cardiac History and Current Symptoms
Primary indication for cardiac catheterization assessment
*
Chest pain
Abnormal stress test
Suspected coronary artery disease
Heart failure evaluation
Post-MI evaluation
Other
Symptom duration
Symptom severity
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Brief symptom description
Prior cardiac history
Myocardial infarction
PCI/stent
CABG
Arrhythmia
Heart failure
Valve disease
Other
Prior cardiac history details
Rows
Yes
No
Myocardial infarction
1
2
PCI/stent
3
4
CABG
5
6
Arrhythmia
7
8
Heart failure
9
10
Valve disease
11
12
Medications, Allergies, and Safety Factors
Current Medication List
*
Anticoagulant Medications
None
Warfarin
Apixaban
Rivaroxaban
Dabigatran
Edoxaban
Heparin
Enoxaparin
Other
Antiplatelet Medications
None
Aspirin
Clopidogrel
Prasugrel
Ticagrelor
Ticlopidine
Other
Allergy Status
*
No known allergies
Yes, allergies present
Unknown
Allergy Details
Prior Contrast Reaction
*
No
Yes
Unknown
Relevant Safety Factors
Diabetes
Kidney disease
Pregnancy possible
Bleeding tendency
Recent major bleeding
Other
Additional Safety Notes
Pre-Procedure Readiness Assessment
Fasting status
*
NPO since midnight
Clear liquids within last 2 hours
Light meal within last 6 hours
Full meal within last 6 hours
Other
Most recent vital signs
*
Rows
Value
Blood pressure
13
Heart rate
14
Oxygen saturation
15
Temperature
16
Recent lab readiness indicators
Rows
Available
Creatinine / eGFR
17
Hemoglobin
18
Platelet count
19
INR
20
Vascular access site considerations
*
Radial
Femoral
Other
Mobility limitations
Requires assistance to transfer
Uses walker or cane
Wheelchair user
Limited range of motion
Other
Escort or transport plan after procedure
*
Escort confirmed
Transportation arranged
Not yet arranged
Patient will remain overnight
Other
Pre-procedure readiness rating
*
Not ready
1
2
3
4
5
6
7
8
9
Fully ready
10
1 is Not ready, 10 is Fully ready
Clearance checklist
*
Vitals reviewed
Labs reviewed
Access site assessed
Mobility plan documented
Escort or transport confirmed
Acknowledgment and Procedure Readiness Confirmation
Procedure Readiness Confirmation
*
I understand this is a pre-procedure assessment and confirm the information I provided is accurate to the best of my knowledge
I understand this is a pre-procedure assessment and I will follow the pre-procedure instructions provided
I do not confirm at this time
Submit Assessment
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