Sleeping Six to Seven Hours a Night Associated With More Favorable Heart Health

Medication List

Name

DOB

Pharmacy

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Please List Medications *

Patient Label

Reason For Consultation

Medication's Currently ON

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History (Include or attach a list of current medication, allergies and any cardiac test results.)

Allergies

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Date

- Chest pain, typical, atypical
- ? ACS, ? Non - Dx changes, Neg or (?) Troponin level
- History of CHF
- Known LV systolic dysfunction of unclear etiology
- Significant ventricular arrhythmia
- Syncope of unclear etiology
- Borderline or high troponin levels in a setting other than ACS
- Significant cerebrovascular or peripheral atherosclerosis
- Re - evaluation (> 1 yr) in pt's with significant cerebrovascular or peripheral atherosclerosis
- Equivocal or non - DX results from other stress modalities
- Initial evaluation of pt's at intern. or high global CAD risk
- Periodic (>2 yrs) re - evaluation of pt's with intermediate or high global CAD risk
- New or worsening chest pain or ischemic equivalent
- Post MI or ACS for risk stratification (within 3 months)
- Viability in patients with known significant LV dysfunction post re - vascularization
- Periodic (> 1yr) re - evaluation of stable patient with known CAD
- For physiologic asses and/or sym. correlation in pt's with moderate or sever aortic stenosis, mitral stenosis, mitral regurgitation, aortic regurgitation, hypertrophic cardiomyopathy
- Assessment of established or latent pulmonary hypertension

- Chest pain, typical, atypical
- ? ACS, ? Non - Dx changes, Neg or (?) Troponin level
- History of CHF
- Known LV systolic dysfunction of unclear etiology
- Significant ventricular arrhythmia
- Syncope of unclear etiology
- Borderline or high troponin levels in a setting other than ACS
- Significant cerebrovascular or peripheral atherosclerosis
- Re - evaluation (> 1 yr) in pt's with significant cerebrovascular or peripheral atherosclerosis
- Equivocal or non - DX results from other stress modalities
- Initial evaluation of pt's at intern. or high global CAD risk
- Periodic (>2 yrs) re - evaluation of pt's with intermediate or high global CAD risk
- New or worsening chest pain or ischemic equivalent
- Post MI or ACS for risk stratification (within 3 months)
- Viability in patients with known significant LV dysfunction post re - vascularization
- Periodic (> 1yr) re - evaluation of stable patient with known CAD
- For physiologic asses and/or sym. correlation in pt's with moderate or sever aortic stenosis, mitral stenosis, mitral regurgitation, aortic regurgitation, hypertrophic cardiomyopathy
- Assessment of established or latent pulmonary hypertension