cardiac rehabilitation assessment form
TRANSCRIPT
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8/19/2019 Cardiac Rehabilitation Assessment Form
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 1 of 14
pPCI CARDIAC REHABILITATION ASSESSMENT
PATIENT DETAILS GP DETAILS
DOB: Unit No.:
Likes to be called: ......................................... GP Tel No: .............................................................
Tel No’s: ......................................................... Communication issues: .......................................
.......................................................................... ................................................................................
.......................................................................... Religion: ................................................................
M / F Age: ......................... Referral Date: ........................................................
Invited for Rehab: .................................................
NOK Details Rehab Started: ......................................................
Name: .............................................................. Consent Given: YES / NO
Relation: ......................................................... Ethnicity: White / Black / African / Chinese /
Tel No: ............................................................ Black Caribbean / Bangladeshi / Indian / Other:
Referral Source: Consultant / Nurse ............../ GP / Other (please state): ....................................
Assessed By: ME / LS / CS / AS / CH ........................................................................................
EM / TC / HN / MM / KB / TO / RW / HH .............................................................
Datacam: In pt CRass Phase 4 / Discharge
Admiss ionDate Initiating Event Trop InitiatingTreatment Date Consultant DischargeDate
Admission Details: ......................................................................................................................................
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 2 of 14
CARDIAC / VASCULAR MEDICAL HISTORY
TYPE DATE DETAILS TYPE DATE DETAILS
MI Angina
Surgery ACS
PTCA CABG
ArrestValve
Surgery
HeartFailure
Pacemaker
Transplant ICD
Congenital LV Assist
PVD TIA
CVA Other
NONE
GENERAL PAST MEDICAL HISTORY
DETAILS DETAILS
Arthritis / Osteoarthritis Rheumatism
Cancer Back Problems
Asthma Osteoporosis
Bronchitis AIDS/HIV
Emphysema Claudication
Diabetes
Other co-morbidComplaints
Details:
CORONARY HEART DISEASE RISK FACTOR PROFILE
Hypertension Hyperlipidaemia
Smoking Diabetes
Family History Overweight
Excess Alcohol Low Levels of Activity
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8/19/2019 Cardiac Rehabilitation Assessment Form
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 3 of 14
SOCIAL CIRCUMSTANCES
Marital Status: Single / Married / Permanent Partner / Divorced / Widowed
Accommodation: House / Flat / Bungalow / Sheltered / Warden Controlled / Boat / Caravan
/ Nursing Home / Other ..........................................................................
Patient Lives With: Partner / Spouse / Alone / Relative / Dependants / Other ......................Details/Concerns ..................................................................................................................
Working Status: Full Time / Part Time / Retired / Self-employed / Unemployed / Disabled /Looking for Work / Permanently Sick / Temporarily Sick / Student /Gov. Training Scheme / Looks after Family / Other ................................
Job Title: ..................................................................................................................
Social EconomicGroup: I / II / IIIM / IIIN / IV / V
INITIAL ASSESSMENT
Driving Regulations Explained: Y / N / NA ....................................................
Rules of Chest Pain Discussed: Y / N ....................................................
When to call 999: Y / N ....................................................
Cardiac Rehab Info Booklet Provided: Y / N ....................................................
INVESTIGATIONS/TESTS
Test Date Comments
Echo:..............................................................................................................................................
.......................................................................
ETT:
ECG: Rhythm
Rhythm
APPOINTMENTS
Date Details
Rehabilitation Appointments
CRASS
Exercise Start
Graduation
Medical Appointments
Cardiac Investigations
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8/19/2019 Cardiac Rehabilitation Assessment Form
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 4 of 14
NAME DESIGNATION SIGNATURE DATE
MARION ELLIOT Senior Nurse
TRISH OSBALDESTONCardiac
Rehabilitation Nurse
TESSA COBBCardiac
Rehabilitation Nurse
HELEN NOLTECardiac
Rehabilitation Nurse
MIRANDA MOWBRAYCardiac
Rehabilitation Nurse
KATE BLAYNEYCardiac
Rehabilitation Nurse
EMMA MILLSCardiac
Rehabilitation Nurse
RACHAEL WALKERCardiac
Rehabilitation Nurse
CardiacRehabilitation Nurse
HANNAH HINDMARSH Exercise Physiologist
Exercise Physiologist
LYNN SCHOFIELD
Clinical Nurse
Specialist
CAROL SCHOFIELDCardiac
Rehabilitation Nurse
ALEX SMITH Cardiac
Rehabilitation Nurse
CATH HAWLEYCardiac
Rehabilitation Nurse
Exercise Physiologist
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8/19/2019 Cardiac Rehabilitation Assessment Form
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 5 of 14
MEDICATION RECORD
Known Allergies:- ................................................................................................
DRUG GROUPDATE DATE DATE DATE
Name & Dose Name & Dose Name & Dose Name & Dose
Beta Blockers Bisoprolol ...... mg
Atenolol ...... mg
Bisoprolol ....... mg
Atenolol ....... mg
Bisoprolol ....... mg
Atenolol ....... mg
Bisoprolol ...... mg
Atenolol ...... mg
ACE InhibitorRamipril ...... mg Ramipril ....... mg Ramipril ....... mg Ramipril ...... mg
A2 Antagonist
Statin / Fibrates Atorvastatin ..... mgSimvastatin ...... mg
Atorvastatin ...... mg
Simvastatin ...... mg
Atorvastatin ...... mg
Simvastatin ...... mg
Atorvastatin ..... mg
Simvastatin ...... mg
Aspirin75 mg 75 mg 75 mg 75 mg
Other Anti-Platelets Prasugrel
Clopidogrel 75 mg
Prasugrel
Clopidogrel 75 mg
Prasugrel
Clopidogrel 75 mg
Prasugrel
Clopidogrel 75 mg
Digoxin..................mcg .................. mcg .................. mcg .................. mcg
Diuretics
Nitrate
GTN Spray/Tabs
Pre-admissionMedies
Others:- Others:- Others:- Others:-
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8/19/2019 Cardiac Rehabilitation Assessment Form
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 6 of 14
IN PATIENT ASSESSMENTDate:
pPCI FOLLOW UP CLINICDate:
Chest Pain / Wound Pain / Heart FailureCCS 0 / I / II / III / IV
Details: .....................................................................
..................................................................................
..................................................................................
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..................................................................................
..................................................................................
Explanation of Medications: Y / N
Heart Failure Assessed Y / N
Echo Performed Y / N
Comments: ...............................................................
..................................................................................
Chest Pain / Wound Pain / Heart FailureSince previous F/U: Y / N CCS 0 / I / II / III / IV
Details: .....................................................................
.................................................................................
.................................................................................
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.................................................................................
Has GTN: Y / N
Aware of Rules of Chest Pain: Y / N
Reported Side Effects of Medication: Y / N
Details: .....................................................................
.................................................................................
.................................................................................
ACTIVITY NYHA Class I / II / III / IV
1: Per week how many times does pt. do Activity:
Strenuous ............... Moderate ............ Mild ...........
2: Does Pt sweat during activity:
Often Sometimes Never / Rarely
3: Does pt. do 30 mins Activity5 times per week: Y / N
Type of Activity: ........................................................
..................................................................................
Safe Levels of ActivityPost Discharge Discussed: Y / N
..................................................................................
..................................................................................
ACTIVITY NYHA Class I / II / III / IV
Current Activity Levels
Safe: Y / N
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Gym Start Date: .......................................................
Driving Resumed: Y / N
Interested in Exercise Sessions: Y / N
SMOKING ASSESSED Y / N
Never Current Ex-Smoker
Type: Cigarettes / Pipe / Rollups / Cigars
Duration: ...................................................................
Smoke Within 30 mins. of Waking: .................. Y / N
Smoking Cessation support offered: ................ Y / N
Referred to PN ...................................................
Advice Given: ...........................................................
..................................................................................
..................................................................................
..................................................................................
Quit Period: ..............................................................
Daily Consumption: .............. Weekly: ..................
SMOKING ASSESSED Y / N
Never
Current
Is Ex-Smoker of > 1 Month:
Discussed Quit Attempt: .................................. Y / N
Smoking Cessation support offered: ............... Y / N
Referred to PN ...................................................
Advice Given: ..........................................................
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 7 of 14
CARDIAC REHABILITATION ASSESSMENT
Date: END ASSESSMENT
Date:
Chest Pain / Wound Pain / Heart FailureSince previous F/U: Y / N CCS 0 / I / II / III / IV
Details: .......................................................................................................................................................
..................................................................................
..................................................................................
..................................................................................
Has GTN: Y / N
Aware of Rules of Chest Pain: Y / N
Reported Side Effects of Medication: Y / N
Heart Failure Assessed: Y / N
Echo Performed: Y / N
Comments: ...............................................................
..................................................................................
Chest Pain / Wound Pain / Heart FailureSince previous F/U: Y / N CCS 0 / I / II / III / IV
Details: ......................................................................................................................................................
.................................................................................
.................................................................................
.................................................................................
Has GTN: Y / N
Aware of Rules of Chest Pain: Y / N
Reported Side Effects of Medication: Y / N
Heart Failure Assessed: Y / N
Echo Performed: Y / N
Comments: ..............................................................
.................................................................................
ACTIVITY NYHA Class I / II / III / IV
1: Per week how many times does pt. do Activity:
Strenuous ............... Moderate ............ Mild ...........
2: Does Pt sweat during activity:
Often Sometimes Never / Rarely
3: Does pt. do 30 mins Activity5 times per week: Y / N
Type of Activity: ........................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................Role of Exercise inPrevention of CHD Discussed: Y / N
ACTIVITY NYHA Class I / II / III / IV
1: Per week how many times does pt. do Activity:
Strenuous ............... Moderate ............ Mild ...........
2: Does Pt sweat during activity:
Often Sometimes Never / Rarely
3: Does pt. do 30 mins Activity5 times per week: Y / N
Type of Activity: .......................................................
.................................................................................
.................................................................................
.................................................................................
.................................................................................
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SMOKING ASSESSED Y / N
Never
Current
Is Ex-Smoker of > 1 Month:
Discussed Quit Attempt: ...................................Y / N
Smoking Cessation support offered: ................ Y / N
Referred to PN Quit form sent
Advice Given: ...........................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
SMOKING ASSESSED Y / N
Never
Current
Is Ex-Smoker of > 1 Month:
Discussed Quit Attempt: .................................. Y / N
Smoking Cessation support offered: ............... Y / N
Referred to PN Quit form sent
Advice Given: ..........................................................
.................................................................................
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8/19/2019 Cardiac Rehabilitation Assessment Form
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 8 of 14
IN PATIENT ASSESSMENTDate:
pPCI FOLLOW UP CLINICDate:
PSYCHOLOGICAL STATE ASSESSED Y / N
HAD Score: ............................................................
Dartmouth Co-op: Y / N
History of Anxiety and Depression Y / N
Psychological support offered Y / NConcerns voiced: ......................................................
..................................................................................
..................................................................................
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Sexual concerns assessed Y / N
Sexual Counselling offered Y / N
..................................................................................
Return to Work Discussed Y / N
..................................................................................
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..................................................................................
PSYCHOLOGICAL STATE ASSESSED Y / N
HAD Score: ............................................................
Psychological support offered Y / N
Referred for Psychological Counselling Y / N
Comments: ..............................................................
.................................................................................
.................................................................................
.................................................................................
.................................................................................
Sexual concerns assessed Y / N
Sexual Counselling offered Y / N
.................................................................................
Return to Work Discussed Y / N
.................................................................................
.................................................................................
.................................................................................
Interested in information sessions Y / N
DIET/WEIGHT MANAGEMENT
Cholesterol Assessed Y / N
Hx of Chol: Y / N Previous Statin Y / N
Date: ................................ Waist > Hip: Y / N
T Chol: ............................. Benefits of Oily Fish
HDL: ................................ Mentioned: Y / N
LDL: .................................
HDL R: .............................
Trig: .................................
BMI Assessed: Y / N
Height: ..............Weight: ............... BMI: ................
Comments: ...............................................................
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DIET/WEIGHT MANAGEMENT
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ALCOHOL ASSESSED Y / N
Units / Week: ...................
Advice Given: ...........................................................
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ALCOHOL ASSESSED Y / N
Units / Week: ..................
Advice Given: ..........................................................
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8/19/2019 Cardiac Rehabilitation Assessment Form
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 9 of 14
CARDIAC REHABILITATION ASSESSMENTDate:
END ASSESSMENTDate:
PSYCHOLOGICAL STATE ASSESSED Y / N
HAD Score: ............................................................
Psychological support offered Y / N
Referred for Psychological Counselling Y / N
Comments: ...............................................................
..................................................................................
..................................................................................
..................................................................................
Sexual concerns assessed Y / N
Sexual Counselling offered Y / N
..................................................................................
Return to Work Discussed: Y / N..................................................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
PSYCHOLOGICAL STATE ASSESSED Y / N
HAD Score: ............................................................
Psychological support offered Y / N
Referred for Psychological Counselling Y / N
Comments: ..............................................................
.................................................................................
.................................................................................
Sexual concerns assessed Y / N
Sexual Counselling offered Y / N
.................................................................................
Return to Work: Y / N
Date .........................................................................
Full time / Part time / Planned / Unplanned /Unemployed / Looking for work / Temporarily sick / Awaiting further investigation / HGV awaiting ETT .
.................................................................................
.................................................................................
DIET/WEIGHT MANAGEMENT
Cholesterol Assessed Y / N
Date: ................................ Waist > Hip: Y / N
T Chol: ............................. Benefits of Oily Fish
HDL: ................................ Mentioned: Y / N
LDL: .................................
HDL R: .............................
Trig: .................................
BMI Assessed: Y / N
Height: ..............Weight: ............... BMI: ................
Comments: ...............................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
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DIET/WEIGHT MANAGEMENT
Cholesterol Assessed Y / N
Date: ............................... Waist > Hip: Y / N
T Chol: ............................ Benefits of Oily Fish
HDL: ............................... Mentioned: Y / N
LDL: ................................
HDL R: ............................
Trig: ................................
BMI Assessed: Y / N
Height: ..............Weight: ............... BMI: ................
Comments: ..............................................................
.................................................................................
.................................................................................
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ALCOHOL ASSESSED Y / N
Units / Week: ...................
Advice Given: ...........................................................
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ALCOHOL ASSESSED Y / N
Units / Week: ..................
Advice Given: ..........................................................
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 10 of 14
IN PATIENT ASSESSMENTDate:
pPCI FOLLOW UP CLINICDate:
HYPERTENSION BP Assessed: Y / N
BP: ....................HR: ...................... Rhythm: .........
Treated: Y / N
Good Control: Y / N
Salt Intake Discussed: Y / N
..................................................................................
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HYPERTENSION BP Assessed: Y / N
BP: ....................HR: ............ Rhythm: ...................
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DIABETES Blood Sugars Assessed: Y / N
Type I Diet
Type II Tabs
Insulin
Inpatient Blood Sugar Range: ..................................
Hb A1C ......................................................................
Previous Control: ......................................................
Newly Diagnosed: Y / N
Advice Given: ...........................................................
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DIABETES Blood Sugars Assessed: Y / N
Range: .....................................................................
Advice Given: ..........................................................
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Hb A1C .....................................................................
Referred to PN / OCDEM: Y / N
FAMILY HISTORY Assessed: Y / N Mother: .....................................................................
Father: ......................................................................
Siblings: ....................................................................
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FAMILY HISTORY Assessed: Y / N
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8/19/2019 Cardiac Rehabilitation Assessment Form
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 11 of 14
CARDIAC REHABILITATION ASSESSMENTDate:
END ASSESSMENTDate:
HYPERTENSION BP Assessed: Y / N
BP: ....................HR: ............ Rhythm: ...................
Good Control: Y / N
Salt Intake Discussed: Y / N
Comments: ...............................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
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HYPERTENSION BP Assessed: Y / N
Pre-Exercise
BP: ....................HR: ............ Reg. / Irreg. ..............
Post-Exercise
BP: ....................HR: ............ Reg. / Irreg. ..............
Good Control: Y / N
Salt Intake Discussed: Y / N
Comments: ..............................................................
.................................................................................
.................................................................................
DIABETES Blood Sugars Assessed: Y / N
Result Date: ..............................................................
Blood Sugar Assessed: .....................Random / Lab
HBA1C: ....................................................................
Effective Control: Y / N
Advice Given: ...........................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
..................................................................................
Referred to PN / OCDEM: Y / N
Attends Practice for Monitoring: Y / N
DIABETES Blood Sugars Assessed: Y / N
Result Date: .............................................................
Blood Sugar: Assessed .....................Random / Lab
HBA1C: ....................................................................
Effective Control: Y / N
BM pre- Exercise: ....................................................
BM post-Exercise: ...................................................
Advice Given: ..........................................................
.................................................................................
.................................................................................
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Referred to PN / OCDEM: Y / N
Attends Practice for Monitoring: Y / N
FAMILY HISTORY Assessed: Y / N
Discuss with the Patient the Healthof their Children : Y / N
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FAMILY HISTORY Assessed: Y / N
Discuss with the Patient the Healthof their Children : Y / N
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8/19/2019 Cardiac Rehabilitation Assessment Form
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 12 of 14
ATTENDANCE / APPOINTMENT INFORMATION
NAME: ..................................................................................................................................................
Patient has dates for the Information Sessions: Y / N
Horton Information Sessions
Week Topic Date
1 Healthy Eating
2 Understanding Heart Disease
3 Emergency First Aid
4 Pharmacist and Blood Pressure
5 Risk Factor Summary
6 Physical Activity and Heart Disease
7 An Introduction to Relaxation
8 Managing Day to Day Stresses
JR Information Sessions
Week Topic Date
1Understanding Heart DiseasePhysical Activity
Stress and Relaxation
2MedicationsHealthy Eating and Food LabellingCBT
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8/19/2019 Cardiac Rehabilitation Assessment Form
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CRF v4.5Pathway Oct2011 Oxford University Hospitals NHS Trust To be Reviewed Oct 2012 13 of 14
CARDIAC REHABILITATION EXERCISE ASSESSMENT
NAME ............................................. AGE ...... EXERCISE START DATE
Grad Date
.....................................
.....................................
PROGRESS (since discharge – note any symptoms)
If surgical 12 weeks since op:
CURRENT PA (FITT) and advice given GTN Y NOn Person? Y N Guidelines? Y N
PREVIOUS PA
EXERCISE LIMITATIONS ADAPTIONS TO EXERCISE
POSSIBLE MEDS SIDE EFFECTS / PA CONSIDERATIONS PATIENT CONCERNS
PATIENT GOALS ADDITIONAL COMMENTS
Actual / Predic ted
MRH ..................... RHR ................. HRR ................... BB? Y N
TRH40% ...................... 50% ................. 60% .............. 70% ................... 80% ...................
RISK STRATIFICATION LOW MODERATE HIGH Permission required Y N
Comments: Permission received Y N
CHECKLIST Discussed w ith Patient
Up to 10 Weeks? Y N
Sensible Precautions? Y N
Warm up / Cool down? Y N
Effort score? Y N
Safety advice? Y N
Exercise book given? Y NHome exercise? Y N
EP INITIALS ........................ SIGNATURE ............................................................. DATE ............................
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SUPERVISED EXERCISE PROGRAMME Site: Horton / Abingdon / BBL / Witney
Start Date: ................................................. Finish / Discharge Date: .........................................................
Graduated: Y / N If No reason for Discharge: ....................................................
No. of Sessions Attended ........................ % of Gym Attendance .............................................................
Plan For Future Exercise
Exercise Level Achieved: .........................mins Phase IV
Exercise HR Achieved: .............................bpm Exercise Referral Scheme
Target HR: ................................................bpm Independent Gym
Working at RPE: ..................(Borg 0-10 scale) Independent Exercise
Limitations During Exercise: ............................ No Regular Exercise
............................................................................................................................................................
Referral Form Required: Y / N Referral Form Completed: ........................................
Sent To: ..............................................................................................................................................