ExRx AI - Patient Form
Patient Name
Patient Age Group
Select Age Group
<5
Elementary School
Middle School
High School
Adult 18+
Exercise Level
Select Exercise Level
Beginner (0-2 days/week)
Intermediate (3 days/week)
Advanced (4+ days/week)
Exercise Duration
Select Exercise Duration
0 minutes
5-15 minutes
20-30 minutes
30-60 minutes
Cardiac Diagnosis
Select Diagnosis
Simple CHD
Complex CHD
Single Ventricle CHD
Cardiomyopathy
Transplant
Coronary Artery Abnormality
Pulmonary Hypertension
Arrhythmia
Autonomic Dysfunction
No Known Heart Disease
Cardiac Considerations
Select Considerations
FORCE Exercise Risk Level
Select Risk Level
Level 1
Level 2
Level 3
Comments
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