Downloadable Online Forms

Downloadable Online Forms

PCNA's Online Forms Guide includes downloadable PDF templates of clinical forms and patient handouts that you can use in your CVD risk reduction practice. These forms can be integrated into patient medical records; they include patient assessment forms, contracts, flow charts, follow-up plans & tools, patient-education materials, and a list of online resource.

PCNA hopes that these forms will enhance your practice by allowing you to provide the best care to your patients by reducing their cardiovascular risk factors and help them reach treatment goals.

How Do I Customize These Forms?

Most of these forms include interactive fields in which you may enter patient and clinical information. Please click here for a sample and instructions on entering this information.

  1. Patient Assessment   (Chapter 1 PDF)
    1A Cardiovascular Risk Assessment Sheet
    1B Cardiovascular Risk Assessment Sheet continued
    1C Primary Prevention Patient Assessment Tool
  2. Flow Charts   (Chapter 2 PDF)
    2A Cardiovascular Risk Assessment Flow Sheet
    2B Cardiovascular Risk Assessment Flow Sheet continued
  3. Contracts and Self-Monitoring Logs   (Chapter 3 PDF)
    3A Self Contracts for Risk Factor Intervention
    3B Written Agreement for Risk Factor Intervention Groups
    3C Daily Exercise Log
    3D Daily Monitoring Log for Patients with Heart Failure

  4. Evaluation Tools   (Chapter 5 PDF)
    5A1-2 Body Mass Index
    5B National Cholesterol Education Program Adult Treatment Panel III
    5C Estimating 10 year Risk for Men and Women
    5D Non-HDL-C
  5. Peripheral Arterial Disease (PAD)   (Chapter 6 PDF)
    6A Ankle-Brachial Index (ABI) Worksheet
    6B Performing the ABI Test
    6C Exercise Program for Individuals with PAD
  6. Diabetes   (Chapter 7 PDF)
    7A1-2 Risk Factors or Complications and Recommended Treatment Goals
    and Frequency of Evaluation for Adults with Diabetes
    7B Signs and Symptoms of Hypoglycemia
    7C Signs and Symptoms of Hyperglycemia
    7D Blood Glucose Monitoring Logs for Patients with Diabetes
    7E Patient Lab Result Sheet
  7. Nutrition   (Chapter 8 PDF) Serving Size Card
    8A1-2 Nutrition Record
    8B Nutrient Content of Tree Nuts
    8C Saturated Fat, Total Fat, Cholesterol, and Omega-3 Content of Meat, Fish, and Poultry
    8D1-2 Mediterranean Diet Food Guide
    8E-1 Sample Menu American Cuisine - Male
    8E-2 Sample Menu American Cuisine - Female
    8E-3 Sample Menu Lacto-Ovo Vegetarian - Male
    8E-4 Sample Menu Lacto-Ovo Vegetarian - Female
    8E-5 Sample Menu Southern Cuisine - Male
    8E-6 Sample Menu Southern Cuisine - Female
    8E-7 Sample Menu Asian Cuisine - Male
    8E-8 Sample Menu Asian Cuisine - Female
    8E-9 Sample Menu Mexican-American - Male
    8E-10 Sample Menu Mexican-American - Female
    8F The DASH Eating Plan Connection
    8G1-2 MyPyramid
    8H Portion Control — How Much Food is Enough?
  8. Stress Management   (Chapter 9 PDF)
    9A Steps Required to Elicit the Relaxation Response
    9B Slow, Deep Breathing Practice
    9C Body Scan Exercise
    9D Guided Imagery Practice- Going to a Special Place
  9. Follow-Up Tools   (Chapter 10 PDF)
    10A Primary and Secondary Prevention Checklist
    10B Patient Lab Results
    10C Patient Plan
    10D Cardiovascular Risk Assessment Return Visit
    10E Follow-Up Visit
  10. Patient Education   (Chapter 11 PDF)
    11A Warning Signs for Heart Attack and Stroke
    11B Fit Walking into your Life with the 10,000 Steps a Day Program
  11. Exercise   (Chapter 12 PDF)
    12A Benefits of Exercise/Physical Activity
    12B How to Start an Exercise Program
    12C Exercise: Goal Setting
    12D Tips for Sticking With It!
    12E Exercise Program for Individuals with Heart Disease
    12F Exercise Tips for Individuals with Heart Disease
    12G Exercise for Healthy Older Adults: Benefits
    12H Exercise for Healthy Older Adults: Getting Started
    12I Exercise for Healthy Older Adults: Safety First
    12J Exercise for Healthy Older Adults: Measuring Your Progress
    12K Exercise Goal-Setting Worksheet
    12L Weekly Exercise and Physical Activity Plan
    12M Endurance Daily Record
    12N Activity/Exercise Log/Journal
    12O Patient Exercise Prescription
    12P Behavioral Management Strategies for Initiating and Maintaining Exercise Adherence
  12. Information on Smoking Cessation   (Chapter 13 PDF)
    13A Getting Started: Ten Key Guideline Recommendations
    13B Always Identify and Assess Tobacco Users in Your Practice
    13C The 5As Model for Treating Tobacco Use and Dependence
    13D For the Patient Willing to Quit
    13E FDA-Approved Smoking Cessation Medications
    13F Promoting the Motivation to Quit for the Patient Unwilling to Quit
    13G Promoting the Motivation to Quit for the Patient who has Recently Quit
    13H Recommendations to Clinicians When Addressing Weight Gain
    13I Seven Steps for People Who Want to Quit Smoking
    13J Log for Tracking My Smoking Habit
    13K Plan for Your Smoking Urges: What to Do Instead of Smoking!
    13L How to Administer and Score the Smoking Confidence Questionnaire: For the Healthcare Professional
    13M Smoking Confidence Questionnaire
    13N Tips for When You Have Stopped Smoking or Relapsed
  13. Medication Adherence   (Chapter 14 PDF)
    14A Patient Medication Schedule
    14B Pearls for Medication Adherence: Patient Form
    14C Pearls for Medication Adherence: Professional Form
  14. Hypertension - Ambulatory and Home Blood Pressure Monitoring (Chapter 15 PDF)
    15A Ambulatory Blood Pressure Monitoring For the Clinician
    15B Home Blood Pressure Monitoring For the Clinician
    15C Home Blood Pressure Monitoring For Patients
    15D Home Blood Pressure Monitoring For Patients- Sphygmomanometers for Self-measurement of Blood Pressure
  15. Models of Behavior (Chapter 16 PDF)
    16A Assessing Readiness To Change- Transtheoretical Model
    16B Self-Efficacy for the Professional: Understanding the Theory Concept
    16C Goal Setting Tips for Lasting Lifestyle Change for the Patient
    16D Goal Setting Worksheet for the Patient
    16E The General Self-Efficacy Scale
  16. Searching the Internet for Cardiovascular Resources   (Chapter 17 PDF)
    17A National Organizations and Major University Sites
    17B Specific Topics (Aging, Physical Fitness, Obesity, Nutrition and Weight Loss)
    17C Pediatric Obesity
    17D Smoking Cessation, Evidence Based Practice
  17. Lipid Reference Values   (Chapter 18 PDF)
    18A Lipid Reference Values— Serum Total Cholesterol
    18B Lipid Reference Values— Serum LDL
    18C Lipid Reference Values— Serum HDL
    18D Lipid Reference Values— Serum Triglycerides

Please be aware that these forms include a sample of current clinical guidelines. However, clinical guidelines (federal, state, local, or those issued by clinical organizations) change over time, so the reader should remember to investigate any recent legal or clinical developments. 

Section 4 of these Forms contains lists and information on commonly used medications. These lists and the information about the medications are not meant to be exhaustive. Consult complete guidelines for a more comprehensive review of indications and clinical follow-up recommendations. All patients should be evaluated based on their state of health, co-morbidities, and other criteria that would guide choices of medical therapy.

This tool is supported by an educational grant from Merck/Schering-Plough and by a grant by the Hartford Institute for Geriatric Nursing at the New York University College of Nursing as part of an initiative called REASN, (Resourcefully Enhancing Aging in Specialty Nursing). The REASN initiative is funded with a $2.3 million dollar grant from The Atlantic Philanthropies (USA) Inc.