Cardiac Rehabilitation Referral
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2Cardiac Rehabilitation Exercise Class-Phase 3 Referral Form
Date of referral:
Client details
Referrer details
(affix sticker if available)
Name:
Name:
Address:
Address:
DOB:
Ph:
Fax:
Ph:
Signature:
UMRN:
Specialist
PT
Other
Cardiac diagnosis/cardiac risk factors:
Eligibility for referral:
Successfully Completed Phase 2 Cardiac Rehabilitation
6MWD<500m or 20MWD< 1400m
Diagnosis of stable Heart Failure (NHYA Class II or III)
OR
Diagnosis of IHD with significant de-conditioning
AND
>1 hospital admission for heart disease in the previous 12 months
*Please attach summary of patient’s medical history and current medications
Cardiac investigations:
(attach reports if available)
________________
Ejection fraction:
(value if known or description e.g. low, poor)
Relevant PMHx:
Musculoskeletal Disease
Specify
Other, please specify
6 minute walking test results Date:
Distance
BP
SpO
Heart rate
Dyspnoea
Rests
2
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Parent category: Medical