Name: Last First M Gender: M / F DOB: / / Age: Email Address: Address: City State Zip Preferred Contact Number: ( ) - Alternative Contact Number: ( ) - Emergency Contact: Relationship: Name Emergency Contact Number: ( ) - Alternative: ( ) - Primary Care Physician: Phone ( ) - Cardiologist: Phone ( ) - Pulmonologist: Phone ( ) - CARDIAC OR PULMONARY HISTORY Have you had or have: NOTES (STAFF USE) Heart attack Angina Congestive heart failure Valve replacement Bypass surgery Pacemaker AICD or defibrillator Heart Transplant Family history of heart disease Arrhythmia or irregularity Bronchoscopy Lung reduction surgery Lung transplant ADDITIONAL NOTES PERTAINING TO CARDIAC OR PULMONARY HISTORY (STAFF USE)
MEDICAL HISTORY Self Family Diagnosis NOTES (STAFF USE) High Blood Pressure Elevated cholesterol or lipids Diabetes Glucose monitoring? Overweight Sleep apnea Asthma Emphysema or Bronchitis Peripheral vascular disease Cancer GERD (Reflux) Stomach ulcer Stroke or TIA Aneurysm Heart irregularity Fainting Arthritis Recent Fall? Y / N EIM Membership Application / Initial Assessment Other ADDITIONAL NOTES PERTAINING TO MEDICAL HISTORY (STAFF USE) Date last in hospital Date of last surgery Current restrictions Surgeries PROFESSIONAL/CULTURAL INFORMATION Retired Employed Type of employment: Work Hours: If you are currently working, please describe the physical requirements that are needed for your job: ADDITIONAL NOTES PERTAINING TO PROFESSIONAL/CULTURAL INFORMATION
SUPPORT SYSTEM EIM Membership Application / Initial Assessment Significant other: Relationship: No. in Household: th: My biggest support: ADDITIONAL NOTES PERTAINING TO PATIENT SUPPORT SYSTEM (STAFF USE) PHYSICAL ACTIVITY Yes No Exercise / Activity Are you currently exercising regularly? Date started: / / Type? How often? For how long? Do you consider it (circle one): Strenuous Moderate Light Very Light Do you have exercise equipment at home? Treadmill Bike Weights Have you exercised on a treadmill before? Have you exercised on a stationary bike before? Have you used weights before? Have you been in a structured exercise program before? With exercise or exertion do you experience: - Shortness of breath? - Leg cramps? - Dizziness? - Arm numbness? - Back pain? Has your doctor placed any weight lifting restrictions on you? How much? lbs ADDITIONAL NOTES PERTAINING TO PHYSICAL ACTIVITY (STAFF USE) INDIVIDUAL PROFILE Do you smoke? Yes No Type? Cigarettes Cigars Pipe Smokeless How long? Amount Thought about quitting: Quit date: Do you consume alcohol? Yes No Type? Amount? Rare / Socially
Highest level of education: Preferred style of learning: Lecture/Discussion Video Written Demonstration What would you most like to learn about living with cardiac or pulmonary disease? ADDITIONAL NOTES PERTAINING TO INDIVIDUAL PROFILE (STAFF USE) PAIN ASSESSMENT No complaint of pain at this time Type Pain Scale Current Treatment (STAFF USE) Chest pain None = 0 1 2 3 4 5 6 7 8 9-10 = Most Leg pain None = 0 1 2 3 4 5 6 7 8 9-10 = Most Incision pain None = 0 1 2 3 4 5 6 7 8 9-10 = Most Muscle/joint None = 0 1 2 3 4 5 6 7 8 9-10 = Most Other: None = 0 1 2 3 4 5 6 7 8 9-10 = Most ADDITIONAL NOTES PERTAINING TO PAIN ASSESSMENT (STAFF USE) PERSONAL GOALS What are your personal goals with participation in this program? ADDITIONAL NOTES PERTAINING TO PERSONAL GOALS (STAFF USE)
Member Signature: Exercise Physiologist Signature: Date: Date: Revised 12/04/12