Prosthetic Heart Valve Evaluation Form
Use this form to assess prosthetic heart valve status, symptoms, medications, and recent cardiac testing before or during clinical review.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Sex at Birth
*
Please Select
Female
Male
Intersex
Prefer not to say
Gender Identity
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Prefer not to say
Valve and Cardiac History
Type of Prosthetic Valve
*
Mechanical
Bioprosthetic
Transcatheter
Unknown
Date of Valve Replacement
 -
Month
 -
Day
Year
Date
Valve Location
*
Aortic
Mitral
Tricuspid
Pulmonary
Unknown
Reason for Valve Replacement
Prior Valve Procedures
Known Valve-Related Complications
Current Cardiologist or Heart Clinic
Current Symptoms and Functional Status
Chest pain
*
No
Yes
Chest pain severity
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Shortness of breath
*
No
Yes
Shortness of breath severity
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Dizziness or fainting episodes
*
No
Yes
Swelling in legs or feet
*
No
Yes
Overall symptom trend
*
Improving
Stable
Worsening
Symptom onset, duration, and exercise tolerance
Medications and Treatment Adherence
Current heart-related medications
*
Anticoagulant
Antiplatelet
Beta blocker
ACE inhibitor / ARB
Diuretic
Antiarrhythmic
Other
List medications and dosages
*
Any missed doses in the past 2 weeks?
*
No
Yes, 1-2 doses
Yes, 3-5 doses
Yes, more than 5 doses
Unsure
Medication side effects or concerns
Do you monitor anticoagulation or other treatment levels?
*
No
Yes, home monitoring
Yes, clinic/lab monitoring
Not applicable
Unsure
Recent Tests, Imaging, and Provider Notes
Echocardiogram Date
 -
Month
 -
Day
Year
Date
Recent Tests Completed
ECG
Chest X-ray
Blood work
Other tests
Recent Visits or Encounters
Clinic visit
Hospital visit
Emergency visit
Telehealth visit
Other
Abnormal Findings Reported by Any Provider
Upload Test Reports or Imaging Files
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Brief Provider Notes or Patient-Reported Test Results
Allergies, Medical Conditions, and Relevant History
Known Allergies
None known
Penicillin/Antibiotics
Latex
Iodinated contrast
Aspirin/NSAIDs
Food allergies
Other
History of Endocarditis
Yes
No
Unknown
History of Bleeding Issues
Yes
No
Unknown
History of Stroke or TIA
Stroke
Transient ischemic attack (TIA)
Both
None
Unknown
Relevant Medical Conditions
Heart failure
Kidney disease
Liver disease
Pregnancy or possible pregnancy
Peripheral vascular disease
Diabetes
Other
Other Relevant History
Submit Evaluation
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