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Demographic Info
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Encounter Date
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Encounter Site
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Patient Name
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Family
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Age
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Common City/Village
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Sex
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City/Village (Other)
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Address
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Contact Number
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History
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Past Medical History
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Valve Disease
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Rheumatic Fever
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High Cholesterol
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Hypertension
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Smoking
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Heart Artery Problems
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Family Hx Heart Disease
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Surgical History
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Heart Catheterization
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Valve Repair/replacement
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Coronary Bypass
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Cardiac History
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Pulmonic Disease
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Mitral Disease
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Heart Attack
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Aortic Disease
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Arrhythmia
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Tricuspid Disease
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Syncope
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CHF
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Cardiac Symptoms
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Irregular Heart Beat
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SOB
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DOE
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Edema
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Bloating
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Physical Exam
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Heart Rate
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Blood Pressure
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Respiratory Rate
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Temperature
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Heart Murmur Description (Systolic)
• • •
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Murmur Systolic
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Heart Murmur Description (Diastolic)
• • •
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Murmur Diastolic
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ECG
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ECG Rhythm
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AFIB
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NSR
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ECG Rhythm Comments
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Junctional
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AV Block
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Infarct Location
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Inferior
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Anterior
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Infero-lateral
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Antero-septal
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Infacrt Location Comments
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Lateral
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ECG Findings
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LVH
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RAA
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Infarct
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LAA
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Heart Block
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RVH
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ECF Findings Comments
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ECG Picture
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Echocardiogram
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Left Atrium
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Right Atrium
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Left Ventricle
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Right Ventricle
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Echo Picture
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Valves
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Mitral Valve
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Mitral Valve Severity
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Mitral Valve Normal
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Mitral Valve Stenotic
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Mitral Valve Insufficient
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Aortic Valve
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Aortic Valve Severity
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Aortic Valve Normal
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Aortic Valve Stenotic
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Aortic Valve Insufficient
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Tricuspid Valve
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Tricuspid Valve Severity
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Tricuspid Valve Normal
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Tricuspid Valve Stenotic
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Tricuspid Valve Insufficient
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Pulmonic Valve
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Pulmonic Valve Severity
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Pulmonic Valve Normal
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Pulmonic Valve Insufficient
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Pulmonic Valve Stenotic
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Labs
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Lab Tests
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Strep Test
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ASO Titer
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Recommendations
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Recommendations
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Change Medicine
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Echo
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Recommendation Comments
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CT
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Cardiac Cath
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Plan
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Catheterization Plan
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Catheterization Plan Comments
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Cardiac Intervention
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Vavluloplasty
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PTCA
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Surgery Plan
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Surgery Plan Comments
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Valve Replacement
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Aortic Repair
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CABG
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Medical Plan
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RHD Antibx
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Medical Plan Comments
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CHF Tx
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BP Control
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CAD Tx
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Time to Follow Up
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Time to Follow Up
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Procedure
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