Angina Monitoring Form
Name:
Profile :
| Date | Time | Circumstances | Intensity | Relief |
|---|---|---|---|---|
| ☐ After an effort ☐ After a stressful situation ☐ After an emotion ☐ Exposure to cold ☐ Exposure to heat ☐ Nothing special | ☐ Mild ☐ Moderate ☐ Severe | ☐ With rest ☐ With ______ doses of nitroglycerin Time for relief: ______ minutes ☐ I had headaches ☐ I felt dizzy ☐ I had hot flashes | ||
| Notes: | ||||
| Date | Time | Circumstances | Intensity | Relief |
|---|---|---|---|---|
| ☐ After an effort ☐ After a stressful situation ☐ After an emotion ☐ Exposure to cold ☐ Exposure to heat ☐ Nothing special | ☐ Mild ☐ Moderate ☐ Severe | ☐ With rest ☐ With ______ doses of nitroglycerin Time for relief: ______ minutes ☐ I had headaches ☐ I felt dizzy ☐ I had hot flashes | ||
| Notes: | ||||
| Date | Time | Circumstances | Intensity | Relief |
|---|---|---|---|---|
| ☐ After an effort ☐ After a stressful situation ☐ After an emotion ☐ Exposure to cold ☐ Exposure to heat ☐ Nothing special | ☐ Mild ☐ Moderate ☐ Severe | ☐ With rest ☐ With ______ doses of nitroglycerin Time for relief: ______ minutes ☐ I had headaches ☐ I felt dizzy ☐ I had hot flashes | ||
| Notes: | ||||
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The patient information leaflets are provided by Vigilance Santé Inc. This content is for information purposes only and does not in any manner whatsoever replace the opinion or advice of your health care professional. Always consult a health care professional before making a decision about your medication or treatment.