Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Cardiac Risk Assessment Form
Your information
Full Name *
Date of Assessment
____ / ____ / ________
Blood Pressure (Both Arms)
Lipid Panel Values
Diabetes Status
Smoking Status
- Never smoked
- Former smoker
- Current smoker
- Prefer not to answer
Family History of Premature ASCVD
Risk-Enhancing Factors
Additional details
Chest Pain Characteristics
NYHA Functional Class
Please bring to your visit: ECG/Lab results
Prevention Plan
Provider Signature
Date
Cardiac Risk Assessment Form template from formisoft.com. formisoft.com/intake-templates/cardiac-risk-assessment