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Requested
Illustration:
1.
WHICH OF THE FOLLOWING PROCEDURE WAS COMPLETED?
CORONARY BYPASS
ANGIOPLASTY
(GO TO QUESTION #6)
2.
WHEN WAS BYPASS SURGERY WAS PERFORMED:
Month
Year
3.
AGE WHEN BYPASS SURGERY WAS PERFORMED?
4. HOW MANY GRAFT'S WERE PERFORMED?
1
2 OR 3
4 OR MORE
5.
INDICATE THE TYPE OF GRAFT(S) USED:
IF THERE WAS ANGIOPLASTY DONE IN ADDITION TO BYPASS, SURGERY, PLEASE CONTINUE WITH QUESTION 6, IF NOT GO TO QUESTION 8.
6. WHEN WAS THE CORONARY ANGIOPLASTY PERFORMED?
Month
Year
IF A SECOND ANGIOPLASTY WAS PERFORMED, WHEN:
Month
Year
7. HOW MANY ARTERIES WAS THE PROCEDURE PERFORMED ON:
A SINGLE ARTERY
MORE THAN ONE ARTERY, NUMBER
8.
WHICH CONDITION PRECEDED THE BYPASS OR ANGIOPLASTY ?
HEART ATTACK
CHEST PAIN
IRREGULAR STRESS EKG
EXTREME FATIGUE
OTHER
9. SINCE THE TIME OF THE ANGIOPLASTY OR BYPASS, HAS THE CLIENT EXPERIENCE EITHER OF THE FOLLOWING:
CHEST PAINS
IRREGULAR STRESS EKG
10. APPROXIMATE DATE OF THE LAST EKG;
WITHIN THE LAST 6 MONTHS
6 MONTHS TO A YEAR AGO
MORE THAN A YEAR AGO
11.
LIST THE LAST CHOLESTEROL READING, IF KNOWN:
HDL RATIO
12. LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
SYSTOLIC
DIASTOLIC
13. CLIENT'S OCCUPATION
14. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL
15. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL
16.
PLEASE LIST ANY OTHER ILLNESSES OR
IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:
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