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?  ________

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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) _________________________________________________________ _________________________________________________________________________