Symptom:

Vital Sign: PR: ……………… BP: ………………

Angina Functional Class Syncope Dyspnea PND Dizziness Weakness Other: ……………………………………….……………………

Present Clinical Situation:

Symptom Free Previous MI Previous CAGB Previous PTCA

Stable Angina Unstable Angina STEMI NSTEMI HF

Class: ……………… Class: ……………… Date: …..........…... Date: ……….…...