CARDIOVASCULAR-ASSESSMENT SHEET

Date S ample
Patient Name Gender DOB/Age
Cardiovascular History

Review of Systems/Symptoms

Social History

CARDIOVASCULAR RISK FACTORS

Dyslipidemia No#### # Yes ##### Previous RX
Hypertension No ##### Yes ##### BP ____________ Previous RX _____________________
Diabetes No ##### Yes ##### FBS/HbA1c ____/____ Previous RX ___________________
Smoking Current Previous Never
Cigs/Day ##### Year Quit ##### Previous Cessation Methods #### #

Fam Hx CAD :No ________ Yes _________________________________________________

Menstrual Status: Premenopausal Perimenopausal Postmenopausal _______

Physical Activity - Weight History ___________________

Initial diet - None AHA DASH Vegetarian Other
Alcohol Use- Stress Source/Mgmt _________________________________________
Thyroid Dis - No Yes _________ Cancer No Yes ________
Liver Dis - No Yes _________ Bleeding Dis No Yes ________
LIFESTYLE & PAST MEDICAL HISTORY

Headaches- No Yes ________ Liver Dis No Yes ________

Renal Dis - No Yes _________ Insomnia No Yes ________
Past Surgeries Other _____________________________________
Other Family History _______________________________________________________________

CURRENT MEDICATIONS
________________________________________________________________________________
________________________________________ Allergies ________________________________

BASELINE PHYSICAL EXAMINATION

Blood Pressure Heart Rate _______________________
 CARDIOVASCULAR ASSESSMENT SHEET

Chief Complaint/Reason for Evaluation:

HISTORY OF PRESENT ILLNESS Risk Factors For CAD
Fam Hx
Smoking:Pks/Yrs
Quit
Dyslipidemia
DM
HTN
Inactivity
Stress
Weight
Other

Women Only
Pregnant ( ) Yes ( ) No: Planning Pregnancy ( ) Yes ( ) No: G P### Postmenopause ( ) Yes ( ) No
PAST MEDICAL / SURGICAL HISTORY
Hospitalization or Surgery Current Medications
Reason Date

Allergies

MEDICAL HISTORY REVIEW OF SYMPTOMS

Cardiovascular ( ) CAD ( ) Cardiomyopathy ( ) Valvular Dz Wt chg
( ) CHF ( ) Arrhythmia ( ) RHD Dyspnea
Respiratory ( ) COPD ( ) Pulm Embolism ( ) Cough Chest Pain
GI/GU ( ) PUD ( ) Hepatitis ( ) Prostate Peripheral Edema
Renal/Endo ( ) Renal Failure ( ) Thyroid Abdomen
( ) Claudication Numbness ext
Periph Vasc ( ) Carotid ASO ( )
Neurological AAA ( ) Seizure ( ) Migraine HA Freq UTI
Mental Health
Heme/On. ( ) CVA/TIA ( ) Cancer
( ) Anemia

FAMILY HX Alive/Well De ceased HTN CAD S troke PVD Diabetes Age/Cause of Death
Father ( )( ( )( ( ) ( )( ( )( ( )( ( )
Mother ) ) ) ( ) ) ) ( )
Siblings ( ) ( ) ( ) ( )( ( ) ( ) ( )
( ) ( ) ) ( ) ( ) ( ) ( )
CVS EXAMINATION:

INSPECTION

o Colour and texture of skin-

o Any suture marks-
o Any dilated engorged superficial veins-
o Inspected precordium-
o Visible pulsations (Apex beat)-

PALPATION

o Any local rise of temperature and tenderness-

o Locate apex beat-
o Parasternal heave-
o Thrill-

PERCUSSION

Borders of heart:

o Right border-
o Left border-
o Upper border-
o Lower border-

AUSCULTATION

Cardiac areas:

o Mitral areas-
o Tricuspid areas-
o Aortic areas-
o Pulmonary area-

___________________________________ ____________________________________
SIGNATURE OF STUDENT SIGNATURE OF TEACHER