Cardiac Rehabilitation History Update Form
Patient Information
Full Name
Date of Birth
Medical Record Number
Contact Information
Phone Number
Email
Cardiac History
Primary Cardiac Diagnosis
Date of Cardiac Event or Procedure
Previous Cardiac Procedures (List)
Current Medications
List all prescribed medications:
Lifestyle & Risk Factors
Smoking Status
Never Smoked
Current Smoker
Former Smoker
Weight (kg)
Current Activity Level
Sedentary
Lightly Active
Moderately Active
Active
Recent Symptoms or Changes
Describe any new or worsening symptoms:
Additional Comments
Other relevant information: