8/3/2019 Candidate for EECP Therapy V15-0148 Rev 1

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V15-0148 Re

Are You a Candidate for EECP Therapy?

Enhanced External Counterpulsation therapy is a noninvasive treatment for angina andheart failure that is available through this office. Answer the questions below to see if

EECP therapy might be right for you.

Circle the symptoms that affect you:

1. Do you ever get symptoms likethe ones you circled abovewhen walking 1 or 2 blocks onlevel ground or climbing oneflight of stairs at a normal pace? Yes No

2. Do you feel that thesesymptoms limit your activities of

daily living such as householdchores, shopping or leisure? Yes No

3. Do you ever get thesesymptoms at rest, after eating,or just watching television? Yes No

4. Do you ever awaken at nightwith these symptoms?

Yes No

5. Have you decreased youractivity in the past 6 months dueto these symptoms? Yes No

6. Do you avoid activity because youmight get these symptoms? Yes No

7. Do you take nitroglycerin tabletsbefore certain activities to preventthese symptoms? Yes No

8. Are you dissatisfied with yourcurrent quality of life because oflack of energy, symptoms, orinability to engage in your normalactivities of daily living? Yes No

9. Have you ever had bypasssurgery, angioplasty, or stents? Yes, when: ________________ No

10. Do you take the medicationRanexa or ranolazine? Yes No

Present this completed survey to yourphysician/nurse practitioner/physician assistant

Chest pain Shortnessof breath

Pain in the jaw,shoulder, arm,back or above

the stomach

Palpitations Nausea orindigestion

Heavysweating

Faintingspells