Cardiac Rehabilitation Exercise Referral Form 

Name: 	     D.O.B: 	   Age: 

Address: 

	GP details:

Telephone numbers: 	

Most recent cardiac Event :

Previous Cardiac History:

Current Medications:

ETT :

	Angiogram: 
	LV Function:

Past Medical History:

Risk factors:
Ex / smoker 
Raised Cholesterol 
Hypertension 
Physically Inactive 
Stress
Excess Alcohol 
Family History 
BMI 
Stable Type 1 / Type 2 Diabetes

Phase III exercise status:

Start date:      End date:       No of ex sessions attended:
Limitations during exercise: 
Adaptations to exercise: 
Pre-ex HR:  bpm
Pre ex BP:  mmHg 
Training HR:  bpm   RPE:  
Total CV time in Phase III prescription___mins 
Competent in self pacing exercise:    

Type of home ex: 
Frequency per week:
Duration: 
Intensity: 

Comments on Phase III prescription: 

Resumed work: 

Patient goals for activity & any associated CHD risk factors

•	

Patient awaiting further medical/surgical treatment :

CR Professional Signature:                      	            		Date: 
Name and Title: Alan Darby , CR Exercise Physiologist   
Telephone No: 01223 274318

I agree for the above information to be passed on to the Phase IV Exercise Instructor. I understand that I am responsible for monitoring my own responses during exercise and will inform the instructor of any new or unusual symptoms. I will also inform the instructor of any changes in my medication, the results of any investigations or treatment.

Signature:
Name and Title:         	       (please print)

PLEASE NOTE THE INFORMATION ON THIS BACR PHASE III TO IV TRANSFER FORM IS ONLY VALID FOR 6 MONTHS AFTER DISCHARGE FROM PHASE III