Cardiology Pretest Assessment Form
Complete this form before your cardiology pretest so the care team can review your symptoms, history, medications, and key measurements.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Non-binary
Prefer not to say
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Cardiac Symptoms and Current Condition
Chest pain or pressure
*
No
Yes, currently
Yes, recently
Intermittent
Other
Chest pain severity
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Other current symptoms
Shortness of breath
Palpitations
Dizziness
Fainting
Swelling
Fatigue
Other
Shortness of breath frequency
Never
Occasionally
Sometimes
Often
Constantly
Other
Palpitations onset
Today
Within the past week
Within the past month
More than a month ago
Not sure
Other
Dizziness or fainting severity
None
Mild
Moderate
Severe
Other
Additional symptom details or triggers
Medical History and Risk Factors
Relevant medical history
*
Heart disease
High blood pressure
Diabetes
High cholesterol
Prior heart attack
Prior stroke
Heart failure
Other
Current smoking status
*
Never
Former
Current
Occasionally
Other
Alcohol use
Never
Rarely
Moderately
Frequently
Other
Exercise level
Sedentary
Light
Moderate
Active
Very active
Other
Family history of heart disease
None known
First-degree relative
Extended family
Both sides of family
Other
Cardiovascular history details
Rows
No
Yes
Unsure
Heart disease
1
2
3
High blood pressure
4
5
6
Diabetes
7
8
9
High cholesterol
10
11
12
Prior heart attack
13
14
15
Prior stroke
16
17
18
Heart failure
19
20
21
Other medical history notes
Additional health risks
Kidney disease
Sleep apnea
Thyroid disorder
Obesity
Pregnancy
Other
Medications, Allergies, and Prior Procedures
Current Medications
Over-the-Counter Supplements
Medication Allergies
None
Penicillin
Sulfa Drugs
Latex
Iodine
Contrast Dye
Other
Prior Cardiac Procedures
Rows
Procedure
Date
Notes
Cardiac catheterization
22
Angioplasty / Stent placement
23
Coronary artery bypass surgery
24
Pacemaker implantation
25
Implantable defibrillator implantation
26
Ablation procedure
27
Hospitalization for heart condition
28
Prior Hospitalizations Related to Heart Conditions
Additional Relevant History
Pretest Measurements and Appointment Details
Systolic Blood Pressure (mmHg)
*
Diastolic Blood Pressure (mmHg)
*
Heart Rate (bpm)
*
Weight (kg)
Preferred Appointment Date and Time
Submit Assessment
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