Dot Cardiology Letter Form - K+stat Urgent Care printable pdf download

Dot Cardiology Letter Form - K+stat Urgent Care

DOT Cardiology Letter

Date: ______________

K+Stat Urgent Care

930 Hayes Drive Suite B

Manhattan KS 66502

tel. 785.565.0016

FAX 785.565.0003

re: Patient Name:__________________________

Patient D.O.B: ____________________________

Dear Dr. ______________________

Your patient __________________ is applying for a Commercial Drivers License (CDL). The rules have

changed recently and because the patient has had *(click ons: Stents, MI, Angina, pacemaker, heart

failure), the following areas must be addressed by a cardiologist. Please fill out the following and attach

requested studies so that the patient can be successful in their quest for a CDL.

Please check or circle all that apply and please attach requested studies

___ Is asymptomatic.

___Tolerates medications.

___ List medications_________________________________

___ Has a satisfactory exercise tolerance test (ETT).* Please attach copy

___ Has a resting left ventricular ejection fraction (LVEF) greater than or

equal to 40%. Please attach copy

___ Has no electrocardiogram ischemic changes. Please attach copy

___ NOTE: For an initial certification following an MI, an in-hospital post-MI

echocardiogram showing an LVEF greater than or equal to 40% is

sufficient.

___ ______ months or weeks since event

___ Angina

___ ANGINA AT REST

___ CHANGE IN ANGINA PATTERN W/IN 3 MONTHS OF EXAM

___ ABNORMAL ETT

___ ISCHEMIC CHANGES ON REST ECG

___ INTOLERANCE TO CARDIOVASCULAR TX

___ ANNUAL EVALUATION was done on _____________

___ BIENNIAL ETT required at a minimum, date of last ETT___________

___ IF ABNORMAL OR INCONCLUSIVE ETT, IMAGING STRESS TEST date and results if

indicated:_______________________________________________

REQUIREMENTS FOR SPECIFIC MEDICAL CONDITIONS

at least one week after procedure

cleared by cardiologist

Tolerance to medications.

ETT 3 to 6 months after PCI.

May NOT be cleared if: (please check any that apply)

____Incomplete healing or complication at vascular access site;

____Rest angina;

____Ischemic ECG change

documentation of annual pacemaker check

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Dot Cardiology Letter Form - K+stat Urgent Care

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