ADDON HEALTH SCREENING REPORT FORM
Addon Screening Medical Report
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
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POSTERIO-ANTERIOR PA
Comments
Lines / Tubes
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None
Other (please write)
Lines / Tubes (Other)
Lungs
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The lungs are well inflated and clear. Good vascular markings. There is no evidence of pneumonia or pulmonary edema.
Other (please write)
Lungs (Other)
Pleura
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There is no pleural effusion or pneumothroax.
Other (please write)
Pleura (Other)
Heart and Mediastium
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The cardiomediastinal silhouette is normal.
Other (please write)
Heart and Mediastium (Other)
Bones
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The visualised skeleton is normal.
Other (please write)
Bones (Other)
Impression
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No abnormalities detected
Other
Impression (Other)
ECHOCARDIOGRAM REPORT
Indication for Echo
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BASIC HEALTH SCREENING
Technique
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SONOEYE P3 Cardio Probe
1. Chamber Size
LVIDs
LVIDd
2. LV Contraction
LV Contraction
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Good
Other (please write)
LV Contraction (Other)
Regional Wall Motion Abnormalities
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Normal
Hyperkinetic
Hypokinetic
3. Ejection Fraction
Ejection Fraction
%
Ejection Fraction Condition
- Select -
Normal
Mild
Mod
Severe
4. LV Function
LV Function
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Good
Other (please write)
LV Function (other)
5. RV Function
RV Function
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Good
Other (please write)
RV Function (other)
6. Valve Morphology
MV
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No MR, No MS
Other (please write)
MV (other)
TV
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No TR, No TS
Other (please write)
TV (other)
AV
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No AR, No AS
Other (please write)
AV (other)
PV
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No PR, No PS
Other (please write)
PV (other)
Conclusion
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No significant findings
Other (please write)
Conclusion (other)
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
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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
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Normal sinus rhythm throughout all stages. Sinus tachycardia seen but expected given the exercise. No pathological ST abnormalities (depression or elevation). No arrythmias.
Other (please write)
ECG (other)
Add custom comment for ECG?
No
Yes
ECG Custom Comment
Conclusion
- Select -
No significant abnormalities detected.
Other (please write)
Conclusion (other)
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