Coronary Artery Disease Assessment Form Step 1 of 2 50% First Name* Last Name* Email* Date MM slash DD slash YYYY Do you ever have chest pain? Yes No If yes, how often? When did you last use Nitroglycerine for your chest pain? Have you ever had any of these cardiac procedures?(Check all that apply) EKG Angioplasty Arteriogram Coronary Artery Bypass Surgery Heart Catheter Other If other please explainHave you gained or lost any weight? Yes No Do you monitor your blood pressure as prescribed by your physician? Yes No No MD order Last BP reading Have you had a Fasting Lipid profile drawn at least once over the last 12 months? Yes No Lipid Profile Date Total Cholesterol LDL HDL Triglycerides How many drinks of a alcoholic beverage do you have in a typical week? None 1 or less 2 or more How well do you feel you are managing your stress level? Good Fair Poor Have you had any changes in your Coronary Artery Disease medications? Yes No If yes, please list changesHave you achieved your current Coronary Artery Disease goal? Yes No What goal do you want to achieve for your Coronary Artery Disease before your next follow-up?** All medical information will be kept confidential in accordance with HIPAA. Thank you for taking the time to complete the questionnaire. We wish you continued success on your Road To Wellness!CommentsThis field is for validation purposes and should be left unchanged. Δ
