Cardioversion Pre-Assessment Form
Please complete this form prior to your scheduled cardioversion procedure. This information helps your care team prepare for your assessment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Scheduled Cardioversion Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Have you experienced any of the following symptoms in the last 48 hours?
*
Chest pain
Shortness of breath
Palpitations
Dizziness or fainting
None of the above
Are you currently taking any blood thinners (anticoagulants)?
*
Yes
No
Please list your current medications (if any)
Do you have any allergies?
*
Yes
No
If yes, please specify your allergies
When did you last eat or drink anything (including water)?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
I acknowledge that I have followed all pre-procedure instructions provided to me.
*
I acknowledge
Submit Pre-Assessment
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