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Cardiac Therapy Assessment Form (TAF)

CARDIAC THERAPY ASSESSMENT FORM (TAF)

Please review the Disclaimer by clicking on the button labeled "Terms and Conditions Disclaimer" found on the bottom of this page. If you are unsure on filling out parts of this form just leave blank and your assigned practitioner will go over everything with you.

Name*

First

Last

Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Date of Birth*

day

/

month

/

year

If you were to scale your daily cardiac-related issues, how bad can it get? *

Good

1

2

3

4

5

6

7

8

9

10

Bad

Rate your pain in an average day. (10 is the worst)

0

0

10

Select Symptoms or Issue (check all that apply)

CHEST PAIN OR HEART

SHORTNESS OF BREATH

LIGHTHEADEDNESS

NAUSEA

VOMITING

JAW PAIN

NECK PAIN

BACK PAIN

ARM DISCOMFORT

SHOULDER PAIN

COUGHING

COLD SWEATS

EXTREME FATIGUE

FAINTING

DIZZINESS

RAPID HEART RATE (100 beats+/min.)

IRREGULAR HEART BEAT

RESTLESSNESS

CONFUSION

WEAKNESS

ANXIETY

LOSS OF APPETITE

CHANGES IN SLEEP PATTERNS

RESPIRATORY INFECTION

HEART PALPITATIONS

SWOLLEN LEGS

SWOLLEN FEET

SLOW WOUND HEALING

HEART DISEASE

DIABETES

WEIGHT GAIN

POOR DIET

DISEASES OF THE ARTERIES

SMOKING

HIGH BLOOD PRESSURE

OTHER

Weight

Height

Please describe any family history of cardiovascular-related issues below:

Are you a smoker? Please answer Yes or No:

Are you currently in any pain? If so, please describe where:

Any previous cardiovascular complications?

What does your current diet consist of?

How often do you exercise? For how long?

Describe your goals or issues that may not have been covered on our TAF.

Email *We won't rent, sell or barter your email address to third parties"*

EMERGENCY CONTACT - PLEASE PROVIDE NAME, PHONE NUMBER AND THEIR RELATION TO YOU*

Phone-Area Code*

Area Code

-

Phone Number

I have read the Disclosure Agreement, and Agree to the Terms and Condition of this site. I am well aware of this program and I maybe disclosing possible personal information to HRN (Home Rehab Network) To formulate an Interactive Therapy program.

I Agree

11155 Red Run Blvd #210
Owings Mills, MD 21117

1-800-341-5838

hrn@hrn.center

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