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Refer a Patient
Cardiac Therapy Assessment Form (TAF)
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Address
*
Address line 2
State / Province / Region
*
City
*
Zip
*
Date of Birth
*
Day/Month/Year
Over the past few weeks, please rate how you feel, from a HEART standpoint, on an average day
Selected Value:
1
1 being the best to 10 being the worst
Rate your pain on an average day
Selected Value:
1
1 being the best to 10 being the worst
Select symptoms or issues (check all that apply)
CHEST PAIN
SHORTNESS OF BREATH
UNABLE TO EXERCISE
LIGHTHEADED OR DIZZY
BLACK OUTS OR NEAR BLACK OUTS
NAUSEA OR VOMITING
EXTREME FATIGUE
TROUBLE SLEEPING
PALPITATIONS (FEELING RAPID OR IRREGULAR HEART BEATS)
SWELLING OF LEGS, ANKLES, OR FEET
HISTORY OF HIGH BLOOD PRESSURE
HISTORY OF DIABETES
HISTORY OF STROKE
HISTORY OF HIGH CHOLESTEROL
Weight
Height
What is your current smoking status?
Current Smoker
Recent Smoker (in the last 90 days)
Previous Smoker (smoked in the past, >6 months ago)
Non-Smoker
Please describe any family history of cardiovascular-related issues below:
Are you currently in any pain? If so, please describe where:
Any previous heart-related problems (heart attacks, stents, bypass or valve surgery, heart rhythm issues, CHF, etc.) ? Please include estimated dates if possible
How would you describe your current diet? - Examples: very healthy, low fat, diabetic diet, don't pay much attention, vegan, etc.
Do you exercise? What type, how often, and how long?
What are your main goals of entering cardiac rehab?
EMERGENCY CONTACT - PLEASE PROVIDE NAME, PHONE NUMBER AND THEIR RELATION TO YOU Please provide 2 separate people for emergency contact, if possible We also ask that you notify the emergency contacts that you put them on the form, so we could reach them quickly , if needed. We will only reach out in the case of an emergency*
Email
*
We won't rent, sell or barter your email address to third parties
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 may be disclosing possible personal information to HRN (Home Rehab Network) To formulate an Interactive Therapy program.
*
I Agree
Submit
