Talk to your doctor about Cardiovascular Advantages Renew® ECP Therapy
To find out if you’re a candidate for Renew® ECP Therapy:
Please print, then fill out the following and discuss with your doctor. (Right click on your mouse and choose PRINT)
1. Approximately how many episodes of angina or symptoms related to chronic stable angina have you had during the past month? ________
2. What are you doing when you experience these episodes? (check all that apply)
___ Exercising ___ Walking normally ___ Walking quickly or uphill ___ Climbing stairs
___ Just had a large meal ___ During hot or cold weather ___ During times of emotional stress or strain
___ Lifting heavy objects ___ During sexual activity ___ Resting ___ Smoking cigarettes
3. What is the impact your heart disease is having on your life?
Very little impact Significant impact
1 2 3 4 5
4. Have you given up on any activities because of your angina? ___ No ___ Yes
If yes, what have you given up? ______________________________
5. Have you had other invasive forms of treatment for your angina and still experience pain? (e.g. Stents or surgery)
___ Yes ___ No
6. Would you be interested in learning about a non-invasive way to treat angina without surgery and without additional medications? ___ Yes ___ No
7. What other topics do you want to discuss with your doctor?
___ Managing side effects of medication
___ Diet and exercise ___ Treatment options
___ other (Please list) _________________________________________________________ _________________________________________________________________________