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Cardiac Rehabilitation Intake Form
Intake

Cardiac Rehabilitation Intake Form

3 pages•18 fields•HIPAA-ready
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Cardiac Rehabilitation Intake Form

Cardiac Rehabilitation Intake Form

Page 1 of 3

Patient Full Name
Jane Martinez
Date of Birth
03/15/1985
Primary Cardiac Event
Select an option...
Date of Cardiac Event
03/15/1985
Current Cardiac Symptoms
Fatigue
Pain
Nausea
Dizziness
Shortness of breath
Referring Cardiologist
Current Cardiac Medications
Exercise Limitations
Enter details here...
Emergency Contact
Contact person
Insurance Information
Insurance carrier & policy
Submit
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This cardiac rehabilitation intake form provides a thorough assessment tool for patients enrolling in phase II or phase III cardiac rehabilitation programs. It captures detailed information about previous cardiac events (myocardial infarction, bypass surgery, valve replacement, angioplasty), current cardiovascular status, exercise limitations, and risk factor profiles including hypertension, diabetes, cholesterol levels, and smoking history. The form also documents current medications, especially cardiac-specific drugs like beta blockers, ACE inhibitors, and anticoagulants.

The template includes specialized sections for baseline functional capacity assessment, angina symptoms, shortness of breath scales, and patient goals for the rehabilitation program. It collects information about support systems, transportation to sessions, and insurance coverage for cardiac rehab services. This form is essential for creating individualized exercise prescriptions, monitoring progress throughout the program, and ensuring patient safety during supervised exercise sessions in hospital-based or outpatient cardiac rehabilitation facilities.

What's included

  • Cardiac event history and dates
  • Current cardiovascular symptoms
  • Exercise tolerance and limitations
  • Cardiac risk factor assessment
  • Current medications and dosages
  • Baseline functional capacity
  • Referring physician information
  • Program goals and expectations
  • Insurance verification for rehab services
  • Emergency contact details

Who uses this template

  • Hospital cardiac rehab programs
  • Outpatient cardiac rehabilitation centers
  • Cardiovascular recovery clinics
  • Post-surgical cardiac care facilities
  • Heart failure management programs

All form fields

10 fields across 3 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Primary Cardiac EventDropdown
Date of Cardiac EventDate
Current Cardiac SymptomsCheckbox
Referring CardiologistText
Current Cardiac MedicationsMedications
Exercise LimitationsLong Text
Emergency ContactEmergency Contact
Insurance InformationInsurance Info
8 min saved per patient98% patient satisfaction3x faster than paper

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