Cardiac Rehabilitation / Risk Prevention Referral
Patients name: <<Patient Demographics:Full Name>>	
Address: <<Patient Demographics:Address Preferred>>, <<Patient Demographics:Address Preferred City>>, <<Patient Demographics:State>>, <<Patient Demographics:Postcode>>	
DOB: <<Patient Demographics:DOB>>	Gender: <<Patient Demographics:Sex>>	
Phone: <<Patient Demographics:Phone (Home)>>	Mobile: <<Patient Demographics:Phone (Mobile)>>	

		Cardiac Rehabilitation	OR		Healthy Heart Program (Risk Prevention)	

Hospital Admission	
Location:	Patient ID:	
Please provide details if possible:	
Date of Admission:	Date of Referral:	Date of Discharge:	
	
		CABG		Valve Replacement/Repair		CTCA	
	
		Angio		Stent		ICD	
	
		Pacemaker	

Diagnosis	
	
		ESE +ve/-ve (please circle)		NSTEMI		STEMI	
	
		Angina		Heart Failure		LVEF (%)	
	
		Other (Please provide details)	

Relevant Past History:	
<<Clinical Details:History List>>	
Complications:	
<<Clinical Details:Allergies/Adverse Reactions>>	
Limitations:	
	
Medications:	
<<Clinical Details:Medication List>>	

Referring Doctor/ Surgeon: <<Doctor:Name>>	
Name of Discharge Nurse: 	
Address:  <<Practice:Name>>, <<Practice:Address>>	
Phone:  <<Practice:Phone>>	Fax:  <<Practice:Fax>>	
Email:  <<Practice:E-mail>>	Signature:	
Date: <<Miscellaneous:Date>>	Provider No: <<Doctor:Provider Number>>	
Copy to referring cardiologist: