Forms2_Cardiology



















Recommended Subacute Bacterial Endocarditis Prophylaxis
recommended subacute bacterial endocarditis prophylaxis


other

Check the letter below describing the level of exercise tolerance in which the applicant is able to participate.
full active participation with no restrictions
full active participation with moderate exercise
partial active participation with light exercise
limited active participation with no exercise




















Allergies:

Medication/Trigger

Date of the last Reaction

Type of Reaction

Medication Trigger1:textfield
date of the last reaction1
type of reaction1
medication trigger2
date of the last reaction2
type of reaction2
medication trigger3
date of the last reaction3
type of reaction3






















Medications:

Medication / Strength / SIG:

Special Instructions:
medication strength sig1
special instructions1
medication strength sig2
special instructions2
medication strength sig3
special instructions3
medication strength sig4
special instructions4
medication strength sig5
special instructions5







Non-prescription medications we stock in the camp infirmary are listed below: Please check those which we SHOULD NOT administer
non prescription medications








describe any recent operations or serious illness
describe any physical disability effecting camp activity
describe any pertinent findings on examination
















Cardiac Rhythm/Device History
does applicant have a history of dysrhythmias
does applicant have a pacemaker or icd













Pacemaker
pacemaker brand
pacemaker model
pacemaker programmed to
pacemaker mode
pacemaker lower rate
pacemaker upper rate










ICD
icd brand
icd model
[?]
has icd discharged recently and how often















Cardiac Transplant Only
date of transplant
surgeon
name of center
phone
evidence of rejection
[?]
if evidence of rejection then type and grade



































Physical Exam:
height
weight
heart rate
o2 saturation
Blood Pressures:
bp ra
bp la
bp rl
bp ll
Pulses:
pulses rue
pulses lue
pulses rle
pulses lle
cardiovascular
precordial activity
murmurs
neurological
lungs
abdomen
gi gu