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Requested
Illustration:
1.
THE CLIENT'S HEART CONDITION / DIAGNOSIS IS:
HEART MURMUR, TYPE
GRADE
CARDIMYOPATHY, TYPE
CONGESTIVE
RESTRICTIVE
ASYMMETRIC SEPTAL HYPERTROPHY
IDIOPATHIC HYPERTROPHY SUB-AORTIC STENOSIS
CARDIAC ENLARGEMENT OR LEFT VENTRICLE HYPERTROPHY
ARRHYTHMIA, TYPE
CONGESTIVE HEART FAILURE
CHEST PAINS
OTHER
2.
DATE DIAGNOSED
DATE RESOLVED
3.
ARE THERE ANY CURRENT SYMPTOMS?
IF YES, PLEASE DETAIL
4.
WHAT TREATMENTS HAVE BEEN PRESCRIBED?
MEDICATIONS, IF YES, PLEASE DETAIL
PACEMAKER, IF YES, PLEASE DETAIL
SURGERY,
IF YES PLEASE DETAIL TYPE AND DATE
5.
CLIENT'S OCCUPATION
6.
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
EJECTION FRACTION,
DATE:
RESULTS
7. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL
8. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL
9.
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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