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Cardiac Clearance Request Form Template

Streamline Patient Cardiovascular Assessments with Ease

Ensuring a patient's heart health is critical, especially before undergoing major procedures. This Cardiac Clearance Request Form Template is designed for healthcare providers like you, simplifying the process of assessing cardiovascular health. With this template, you can seamlessly collect essential patient information, track cardiac health histories, and communicate effectively with your medical team, all while maintaining compliance with health regulations. It's a straightforward way to enhance patient care and streamline your workflows-explore the live template now.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary phone number
Email address
Preferred contact method
Phone call
Text message
Email
Any
Referring provider full name
Practice or facility name
Referring provider phone
Referring provider email
Reason for cardiac clearance
Please Specify:
Planned procedure date
Procedure urgency
Routine (7+ days)
Soon (3-6 days)
Urgent (within 72 hours)
Unknown
Planned anesthesia type
General anesthesia
Regional/Spinal
Monitored anesthesia care/IV sedation
Local only
Unknown
Known heart conditions (select all that apply)
Prior cardiac procedures (select all that apply)
Coronary stent
Bypass surgery (CABG)
Valve repair or replacement
Cardiac ablation
Pacemaker or ICD implantation
Cardiac catheterization (diagnostic)
None
Other
Please Specify:
Additional cardiac history details (include dates and facilities if known)
Cardiac tests in the past 2 years (select all that apply)
ECG/EKG
Echocardiogram
Stress test (exercise or pharmacologic)
Cardiac catheterization
Cardiac CT or MRI
Holter or event monitor
None
Unsure
Current symptoms (select all that apply)
Chest pain or pressure
Shortness of breath
Palpitations
Dizziness or lightheadedness
Fainting (syncope)
Leg swelling
Exercise intolerance
No symptoms
Functional capacity
No limitation; can do heavy work or strenuous sports
Can climb 2 flights of stairs or walk briskly (4+ METs) without symptoms
Limited to 1 flight of stairs or slow walk (<4 METs)
Symptoms at rest or with minimal activity
Not sure
Cardiovascular risk factors (select all that apply)
Current medications (names and doses)
Blood thinners or antiplatelet medicines (select all that apply)
Allergies (select all that apply)
No known drug allergies
Penicillin
Sulfa drugs
Iodine or contrast dye
Latex
Anesthetics (e.g., lidocaine)
Other
Please Specify:
I authorize the cardiology practice to request and share my medical records related to this clearance
Yes
No
Type your full name as signature
Signature date
The information provided is true and complete to the best of my knowledge
True
False
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paper art illustration depicting a cardiac clearance request form for FormCreatorAI article

When to use this form

Use this form when a surgeon, dentist, or employer needs a heart risk review before surgery, an invasive procedure, strenuous duty, or travel. Your clinic can gather history, medications, recent test results, and specialist input so a cardiologist can advise on risk and restrictions. Attach prior records or request them with the Medical chart review form. If the goal is job clearance after a cardiac event, pair it with the Physician release to return to work form to document duty limits. For comprehensive pre-op data, pull vitals and exam findings from the Adult physical exam form. The outcome is a clear go/no-go decision, any optimization steps, and follow-up timing.

Must Ask Cardiac Clearance Request Questions

  1. What procedure or activity is this clearance for, and what is the target date?

    Knowing the exact event and timeline lets the team match cardiac risk to the situation and plan optimization. It also prioritizes urgent cases and prevents outdated decisions.

  2. What heart conditions, symptoms, and exercise tolerance (for example, how many flights of stairs) do you have today?

    Current symptoms and functional capacity are strong predictors of perioperative risk. Clear detail here reduces back-and-forth and speeds the decision.

  3. Which cardiac tests have you had recently, and what were the dates and results (ECG, echocardiogram, stress test, catheterization, troponin or BNP)?

    Recent objective data supports a safe yes/no or next steps such as more testing or medication changes. Listing dates avoids repeat testing and delays.

  4. What medications and supplements are you taking, including blood thinners and antiplatelet drugs, and any allergies?

    These affect bleeding risk and anesthesia planning. Accurate lists help the team decide on holds or bridging therapy.

  5. What job duties or activity demands will you perform, and will you need a tight-fitting respirator?

    Understanding physical demands aligns clearance with real tasks and restrictions. If respirator use is required, attach the OSHA Respirator medical evaluation questionnaire form to streamline fit testing.

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