Cardiac Risk Assessment Form

The Cardiac Risk Assessment Form provides clinicians with a structured approach to evaluating and stratifying cardiovascular disease risk using validated prediction models and established risk factor frameworks. It captures the essential variables required for Atherosclerotic Cardiovascular Disease (ASCVD) 10-year risk calculation including age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, antihypertensive medication use, diabetes status, and smoking status as defined by the 2013 ACC/AHA Pooled Cohort Equations. The form also documents additional risk-enhancing factors recognized in the 2019 ACC/AHA Primary Prevention Guidelines including family history of premature ASCVD, metabolic syndrome criteria, chronic kidney disease, chronic inflammatory conditions, high-sensitivity C-reactive protein, lipoprotein(a), and coronary artery calcium (CAC) scoring.

This template includes a thorough cardiac symptom assessment evaluating chest pain characteristics using the Diamond-Forrester classification (typical angina, atypical angina, non-cardiac chest pain), dyspnea on exertion graded by NYHA functional class, palpitation characteristics, syncope and presyncope episodes, and peripheral vascular symptoms (claudication, rest pain). The physical examination section captures blood pressure in both arms, heart rate and rhythm, JVP estimation, cardiac auscultation findings (murmurs, gallops, rubs), peripheral pulse assessment, and signs of heart failure (peripheral edema, pulmonary crackles, hepatojugular reflux).

Designed for cardiology practices, internal medicine clinics, preventive medicine programs, and primary care cardiovascular screening initiatives, this form supports quality measure reporting for statin therapy eligibility, blood pressure control targets, and tobacco cessation counseling. It provides the clinical decision support documentation needed for shared decision-making conversations about statin initiation, aspirin therapy, lifestyle modifications, and referral for advanced cardiac testing including stress testing, echocardiography, or coronary artery calcium scoring.