DREAD DISEASE QUESTIONNAIRE - HEART ATTACK

Patient’s name:

D.O.B.:

ID Number:

Address:

Occupation:

Date of the Heart attack:

Dates of Treatment / From :

Dates of Treatment / To :

Did the patient have an irrevocable reduction of the heart muscle systolic function?

Yes

No

Did the patient have medical history of typical angina pectoris pain?

Yes

No

Date when:

Are there any electrocardiographically lesions indicants of an acute heart attack?

Yes

No

If YES, give the dates and type of examinations below: