ECG Only
ECG ONLY FORM Has the patient had a previous ultrasound or echocardiogram with Paw Prints?
CLINIC DETAILS All fields marked with a red asterisk * are required
PATIENT DETAILS All fields marked with a red asterisk * are required
Species
Select One Canine Feline Other
Which studies will you be requesting today for this patient?
Is there a non-IDEXX report from a previous study available for comparison?
If yes, please attach a PDF of the report with the other files for today's case
Please select the indications or clinical signs that prompted this study.
heart murmur abnormal breathing coughing arrhythmia or ECG abnormality exercise intolerance syncope/collapse acute onset paralysis history of grain free or other atypical diet pre-chemotherapy study heartworm positive status other/not listed
Please describe the other/not listed clinical signs. (max 250 chars)
Please select the chronicity of the heart murmur.
Please select any known or suspected triggers for the syncope/ collapse.
Please describe the other/not listed triggers. (max 250 chars)
Please summarize pertinent history and/or elaborate on the clinical signs and study indications. (max 500 chars)
Questions about recent diagnostic tests and medications will appear later.
Was the patient sedated for any part of today's study?
Please select one option.
Currently the patient's appetite is reported to be
Point of maximal intensity
Which of the following best describes the patient's attitude/demeanor?
Any recent changes in body condition?
Please describe any additional relevant physical exam findings (max 500 chars)
Completed diagnostics (max 500 chars)
Please summarize results of any other completed diagnostics. Write "none" if N/A.
Pending diagnostics (max 250 chars)
Please list any pending diagnostics. Leave blank if N/A.
Planned diagnostics (max 250 chars)
Please list any planned diagnostics not yet in progress or performed. Leave blank if N/A.
Please describe any relevant prior treatments the patient received for the current clinical signs. (max 1000 chars)
Please list patient's current cardiac medications. (max 500 chars)
Include drug name, dosage, administration route, and frequency.
Please describe the patient's response to these cardiac medications, if any. (max 500 chars)
Please list any other medications the patient is taking, including supplements.Include drug name, dosage, administration route, and frequency, if possible. (max 500 chars)
Include drug name, dosage, administration route, and frequency, if possible.
Do you need comments on anesthesia for a procedure planned in the short-term future?
Is there any additional medically pertinent information to share
Please provide the medically pertinent information or case impressions (max 250 chars)
Are there any specific clinical questions or concerns you would like addressed in this report? (max 250 chars)
Do you have files to attach?
Maximum 10 files up to 10MB each.
Submit Form
