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Requested
Illustration:
1. LIST DATE (S) OF HEART ATTACK (S) AND SEVERITY
OF EACH:
DATE
MILD,
MODERATE,
SEVERE
HOW LONG UNTIL RETURN TO NORMAL ACTIVITIES?
DATE
MILD,
MODERATE,
SEVERE
HOW LONG UNTIL RETURN TO NORMAL ACTIVITIES?
DATE
MILD,
MODERATE,
SEVERE
HOW LONG UNTIL RETURN TO NORMAL ACTIVITIES?
2.
WHAT CONDITION (S) PRECEDED THE HEART ATTACK (S)?
IRREGULAR STRESS EKG
IRREGULAR EKG
CHEST PAIN
ARRHYTHMIA OR IRREGULAR HEART BEATS
3.
ACTIVITIES CAPABLE OF PERFORMING (CHECKING LEVEL OF EXERCISE THAT BEST APPLIES):
LEVEL ONE- HEAVY LABOR HANDBALL, CROSS COUNTRY, SKIING, RUNNING 10 MINUTE MILES,
BICYCLING AT 12 MPH
LEVEL TWO- SHOVELING, WOOD CUTTING, CANOEING, JOGGING,12 MINUTE MILES, SWIMMING
CRAWL STROKE, ROWING MACHINE.
LEVEL THREE-CARPENTRY, LAWN MOWING, SINGLES TENNIS, DOWNHILL SKIING, SWIMMING
BREAST STROKES
LEVEL FOUR- SEDENTARY LIFE STYLE ( UNABLE TO DO ANY OF LEVELS ONE THROUGH TO THREE)
4.
DATE LAST CONSULTED PHYSICIAN:
WHAT TREATMENT (S) HAVE BEEN PRESCRIBED? LIST ALL
MEDICATIONS
SURGERY?
IF YES, DATE:
SURGERY?
IF YES, DATE:
NUMBER OF ARTERIES OR GRAFTS PERFORMED ON:
DATE:
OTHER TREATMENTS:
5. CLIENT'S OCCUPATION
6.
SINCE THE HEART ATTACK, HAS THE CLIENT EXPERIENCED ANY OF THE FOLLOWING?
CHEST PAINS OR ANGINA
IRREGULAR EKG OR STRESS EKG
ARRHYTHMIA
CONGESTIVE HEART FAILURE
7.
WHAT TESTS HAVE BEEN PERFORMED? (CHECK ALL THAT APPLY)
RESTING EKG,
DATE:
RESULTS
EXERCISE EKG,
DATE:
RESULTS
THALLIUM TEST, DATE:
RESULTS
STRESS ECHO, DATE:
RESULTS
CORONARY CATCH,
DATE:
RESULTS
8. LIST THE LAST CHOLESTEROL READING, IF KNOWN:
HDL RATIO
9. LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
SYSTOLIC
DIASTOLIC
10. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL
11. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL
12.
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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