Cardiac Stress Test Evaluation Form
Complete this form to help the clinic review your cardiac history, symptoms, medications, and test preparation before a cardiac stress test.
Patient Intake
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex at Birth
*
Female
Male
Intersex
Prefer not to say
Preferred Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Email
example@example.com
Clinical History and Symptoms
Current Chest Pain or Discomfort
*
None
Mild
Moderate
Severe
Other
Current Symptoms
Shortness of breath
Dizziness
Palpitations
Fatigue
Nausea
Sweating
Other
Symptom Frequency
*
Rarely
1
2
3
4
Constantly
5
1 is Rarely, 5 is Constantly
Cardiac History
Rows
Yes
No
Prior heart attack
1
2
Angina
3
4
Heart failure
5
6
Arrhythmia
7
8
Stent or bypass
9
10
Hypertension
11
12
Diabetes
13
14
Smoking history
15
16
Family history of heart disease
17
18
Exercise tolerance limitation
19
20
Smoking Status
Please Select
Never
Former
Current
Other
Detailed Symptom Log
Overall Exercise Tolerance
1
2
3
4
5
Medications, Allergies, and Recent Restrictions
Current medications
*
Which of the following are you currently taking?
Beta blockers
Other heart medicines
Blood pressure medicines
Diuretics
Asthma inhaler
Diabetes medicines
None of these
Other
Allergies or adverse reactions
Recent procedures or hospitalizations
Pregnancy status
Not pregnant
Possibly pregnant
Pregnant
Not applicable
Recent caffeine intake, food restrictions, exercise limitations, or mobility issues
Submit
Should be Empty: