Cardiac Rehabilitation Progress Assessment

Cardiac Rehabilitation Progress Assessment — Form Fields

This healthcare template includes 14 fields. Progress assessment form for patients in cardiac rehabilitation programs. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Patient ID (text, required)
• Assessment Date (text, required)
• Cardiac Event Type (text, required)
• Phase of Rehab (dropdown selection, required) — options: Phase 1 (Inpatient), Phase 2 (Outpatient Supervised), Phase 3 (Independent)
• Resting Heart Rate (bpm) (number, required)
• Resting Blood Pressure (systolic) (number, required)
• Resting Blood Pressure (diastolic) (number, required)
• 6-Minute Walk Distance (meters) (number, optional)
• Peak Exercise Heart Rate (bpm) (number, optional)
• Exercise Tolerance (dropdown selection, required) — options: Significantly Improved, Moderately Improved, Slightly Improved, No Change, Declined
• Patient Confidence in Physical Activity (rating, required)
• Lifestyle Modifications Adopted (checkboxes, optional) — options: Heart-Healthy Diet, Regular Exercise, Smoking Cessation, Stress Management, Medication Compliance, Weight Management
• Clinical Notes (long text, optional)