Cardiac Catheterization Form

Patient Name
DOB Sex M F
PHN
Address City
Prov Postal Code
Patient Information or Label / Addressograph

Information marked with *is mandatory

DATE* Physician Telephone

→ FAX Referral Form, History/Consult, ECG, lab results, MAR and Echo to Requested
Hospital
PATIENT
LOCATION* Hospital (Inpatient) Unit Unit phone # Home (Outpatient)
Emergent → For emergent cases please phone the on-call Interventionalist at the requested
URGENCY* hospital
Urgent In-Hospital (24 to 48 hrs; max 5 days) Urgent Out of
Hospital (within 2 wks) Elective (within 6 wks)
ALLERGIES No Known Local Anesthetic Contrast ASA Other
Diagnostic Right Heart Cath Aortogram 1st Available Physician
PROCEDURE Cath TAVI workup Myocardial Specific Physician
Cath +/- PCI Pulmonary Biopsy
REQUESTED* Resistance
PCI (planned Other
PCI)
STEMI → If Fibrinolysis: Date Time
NSTEMI → Ischemic ECG changes (ST or T) → Positive troponin/marker Result
Unstable → Current Symptoms: Ongoing Re-MI Recurrent Pain CHF
Angina Arrhythmia None
Stable Angina
INDICATION* Valvular Heart Disease Congenital
Arrhythmia
→ Aortic Transplant ○ Pre ○ Post
Heart Failure
→ Mitral Research
Cardiomyopat → Other Other
hy
IV Inotropes LMWH ASA Warfarin
CURRENT IV Insulin Clopidogrel Prasugrel → Will hold prior to procedure
Nitroglycerin Metform Ticagrelor Other → Will require bridging therapy
MEDICATION IV IIb/IIIa Dabigatran → Perform on Anticoagulation
IV Heparin in
S
Hypertension Cerebrovascular Event ○ Prior
Dyslipidemia Stroke ○ Prior TIA
Diabetes ○ Type I ○ Type II Renal Insufficiency ○ Acute ○ Chronic
Smoking ○ Current ○ Former Dialysis ○ HD ○ PD
COPD Peripheral Vascular Disease
CO-MORBIDITIES Prior MI History of Heart Failure
Prior PCI Suspected LV Thrombus
Prior OHS ○ CABG ○ Valve GI Bleed within 1 year
Other
CCS ANGINA Within 2 weeks I II III IV IVa IVb IVc

CLASS*
NYHA CLASS* Within 2 weeks I II III IV n/a

PRIOR NON- Exercise Stress Test Date Result: Positive Negative LVEF %
INVASIVE Indeterminate Source
TESTS
MIBI Other Date Result: Positive
 Negative Indeterminate

LAB VALUES* Creatinine* Hgb* WBC Troponin eGFR Platelets INR Other

HEIGHT/WEIGHT Height cm Weight kg

SPECIAL
INSTRUCTIONS/
BRIEF HISTORY
Referring Physician’s Signature* Accepting Physician’s Signature Acceptance Date (dd/mm/yyyy)