Cardiac Catheterization Intake Form
Use this form to provide the information needed before your cardiac catheterization appointment or procedure.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Procedure and Referral Details
Procedure Type
*
Planned elective procedure
Follow-up evaluation
Urgent evaluation
Procedure Date and Time
*
Referring Physician/Cardiologist Name
*
First Name
Middle Name
Last Name
Reason for Cardiac Catheterization
*
Facility or Department Name
Symptoms and Cardiac History
Current Symptoms
*
Chest pain
Shortness of breath
Palpitations
Dizziness
Fainting
Swelling in legs/feet
Fatigue
No current symptoms
Other
Symptoms Trigger or Pattern
At rest
With activity/exertion
After meals
At night
Intermittent
Constant
Worsening over time
Improving
Other
Prior Heart Attack or Acute Coronary Event
No
Yes, one episode
Yes, more than one episode
Not sure
Known Cardiac History
*
Coronary artery disease
Heart failure
Abnormal stress test
Prior catheterization
Prior angioplasty
Prior stent placement
Arrhythmia
Valve disease
Cardiomyopathy
Other
Other Relevant Cardiac Conditions
High blood pressure
High cholesterol
Peripheral artery disease
Stroke or TIA
Family history of early heart disease
Congenital heart disease
History of heart surgery
Other
Medications and Allergies
Current medications
Are you taking any blood thinners or anticoagulants?
*
No
Yes
Not sure
Allergies
Medications
Latex
Iodine/contrast
Food
Other
Allergy reaction details
Pre-Procedure Screening and Consent
Are you currently pregnant or could you be pregnant?
*
Yes
No
Not applicable
Unsure
Consent to proceed with procedure preparation
*
Submit
Submit
Should be Empty: