ADDON HEALTH SCREENING REPORT FORM
Addon Screening Medical Report - Form 2 (Dr Reza)
IC No. / Passport No.
Date of Birth
Date of Screening
Type of Screening
X-Ray
Echocardiogram
Stress Test
ECG
X-RAY REPORT
Indication
- Select -
BASIC HEALTH SCREENING
Technique
- Select -
POSTERIO-ANTERIOR PA
Comments
Lines / Tubes
Lungs
Pleura
Heart and Mediastium
Bones
Impression
ECHOCARDIOGRAM REPORT
Indication for Echo
- Select -
BASIC HEALTH SCREENING
Technique
- Select -
SONOEYE P3 Cardio Probe
1. Chamber Size
LVIDs
LVIDd
2. LV Contraction
LV Contraction
- Select -
Good
Other (please write)
LV Contraction (Other)
Regional Wall Motion Abnormalities
- Select -
Normal
Hyperkinetic
Hypokinetic
3. Ejection Fraction
Ejection Fraction
%
Ejection Fraction Condition
- Select -
Normal
Mild
Mod
Severe
4. LV Function
LV Function
- Select -
Good
Other (please write)
LV Function (other)
5. RV Function
RV Function
- Select -
Good
Other (please write)
RV Function (other)
6. Valve Morphology
MV
- Select -
No MR, No MS
Other (please write)
MV (other)
TV
- Select -
No TR, No TS
Other (please write)
TV (other)
AV
- Select -
No AR, No AS
Other (please write)
AV (other)
PV
- Select -
No PR, No PS
Other (please write)
PV (other)
Comment
Conclusion
STRESS TEST REPORT
85% Cardiac Reserve
BPM
Screening
Stress Test Type
Acute MI in < 3days
Unstable Angina not on tx
Uncontrolled Arrhythmias
Pulmonary Embolism
Pulmonary Hypertension
Severe Aortic Stenosis
Myocarditis / Pericardits
Aortic Dissection
Heart Failure
Any contraindication?
Yes
No
Start Time
Pre Test
Supine
BP
HR
Exertion Score (6-20)
Standing
BP
HR
Exertion Score (6-20)
Stage 1
BP
HR
Exertion Score (6-20)
Stage 2
BP
HR
Exertion Score (6-20)
Stage 3
BP
HR
Exertion Score (6-20)
Stage 4
BP
HR
Exertion Score (6-20)
Stage 5
BP
HR
Exertion Score (6-20)
Stage 6
BP
HR
Exertion Score (6-20)
Stage 7
BP
HR
Exertion Score (6-20)
Stage 8
BP
HR
Exertion Score (6-20)
Completed Stress Test Stages
- Select -
1
2
3
4
5
6
7
8
End Time
Recovery
0:30 sec
BP
HR
Exertion Score (6-20)
1:00 min
BP
HR
Exertion Score (6-20)
5:00 min
BP
HR
Exertion Score (6-20)
ECG
ECG
ECG Comment
ECG Conclusion
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