Cardio Connect Pre-Exercise Screening Tool

Dr. A. Fahoum, MD

Suite 103-51 Inglewood DrSt Albert, AlbertaT8N 4E7

Cardio Connect Pre-Exercise Screening Tool

This is the electronic version of the Cardio Connect Pre-Exercise Screening Tool. You can use this tool to determine whether or not your patient is healthy enough for exercise, healthy enough to undergo a Cardiac Exercise Stress Test or healthy enough to benefit from an Exercise Prescription from Cardio Connect.

This form can also be used as a referral—just fill in the required fields and hit “Send” to refer your patient to Cardio Connect.

If you would prefer to download and fax a referral form, please click here.

Patient Information

Referring Physician

History

You have had:

Symptoms
Other health issues

If you marked any of these statements in this section, consult your physician or other appropriate healthcare provider before engaging in exercise. You may need to use a facility with a medically qualified staff.

Cardiovascular risk factors

If you marked any of these statements in this section, consult your physician or other appropriate healthcare provider before engaging in exercise. You may need to use a facility with a medically qualified staff.


Please leave this field empty.

*This form is valid for 12 months only, and as long as the answers to any of those questions have not changed.

**This form is developed based on guidelines of the American Heart Association and American Society of Sports Medicine, and is the sole property of Cardio Connect.