Cardiac Rehabilitation Physical Therapy Intake Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Emergency Contact
Contact Name
Relationship
Contact Phone
Medical Information
Primary Cardiac Diagnosis
Date of Onset/Event
Recent Hospitalizations (past 6 months)
Current Medications
Allergies
Relevant Medical History (e.g. diabetes, hypertension, stroke, etc.)
Physical Activity
Current Activity Level
Sedentary
Light
Moderate
Active
Exercise Limitations or Symptoms (e.g. chest pain, shortness of breath)
Goals for Rehabilitation
What are your primary goals for cardiac rehabilitation?