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Heart Catheterization Form
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Patient & Procedure Details
Last Name
First Name
Your Clinic/Hospital
Physician Performing Procedure
Dr. Jaime Lewellyn, DO
Dr. Richard Zelman, MD
Procedure to be Performed
Quick Add:
Cath w/ PCI
Right Heart Cath
PCI
Procedure Location
Martin North Hospital
Tradition Hospital
Date of Procedure
Arrival Time
Facility's Phone Number
Medication Checklist
Coumadin/Warfarin
No
Yes
Eliquis/Xarelto/-xaban
No
Apixaban
Betrixaban
Edoxaban
Eliquis
Xarelto
Insulin-Long Acting
No
Inuslin Glargine
Basaglar
Lantus
Toujeo
Insulin Detemir
Levemir
Insulin Degludec
Tresiba
Insulin-Short Acting
No
Regular(R)
Novolin
Velosulin (For Insulin Pump)
Metformin
No
Metformin
Glumetza
Riomet
Metformin-alogliptin (Kazano)
metformin-canagliflozin (Invokamet)
metformin-dapagliflozin (Xigduo XR)
metformin-empagliflozin (Synjardy)
metmorfin-ertugliflozin (Segluromet)
metformin-glipizide
metformin-glyburide (Glucovance)
metformin-linagliptin (Jentadueto, Jentadueto XR)
metformin-pioglitazone (Actoplus Met, Actoplus Met XR)
metformin-repaglinide (PrandiMet)
metformin-rosiglitazone (Avandamet)
metformin-saxagliptin (Kombiglyze XR)
metformin-sitagliptin (Janumet, Janumet XR)
Sulfonylureas
No
glimepiride (Amaryl)
glimepiride-pioglitazone (Duetact)
gliclazide
glipizide
glipizide ER (Glipizide XL, Glucotrol XL)
glipizide-metformin
glyburide (Glynase)
glyburide-metformin
ED Medications
No
Avanafil/ Stendra
Cialis
Sildenafil
Tadalafil
Vardenafil
Viagra
GLP1 Agonist/-tide
No
dulaglutide (Trulicity)
exenatide (Byetta, Bydureon)
liraglutide (Victoza, Saxenda, Xultophy)
lixisenatide (Adlyxine, Soliqua)
semaglutide (Ozempic, Wegovy, Rybelsus)
tirzepatide (Mounjaro)
SGLT2 Inhibitors/-flozin
No
canagliflozin (Invokana)
dapagliflozin (Farxiga)
empagliflozin (Jardiance)
ertugliflozin (Steglatro)
sotagliflozin (Inpefa)
Generate & Print Report
Medication Instructions
Day of Procedure
- Do NOT eat or drink anything after midnight before procedure.
- DO take any of your regular medications the morning of procedure unless advised otherwise.
- Your family will be shown to the waiting room and will receive periodic updates.
- The physician will talk with you or your family after the procedure.
Call the office if...
- any questions regarding procedure
- you develop an infection that requires antibiotics of any kind
- there is any change in your condition
- you develop a fever, cold, or flu symptoms
- are prescribed new medications