Norwegian Forest Cat HCM DNA Research Project
US HCM Screening Form
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PATIENT INFORMATION
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OWNER/AGENT NAME:
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ADDRESS: | CITY/STATE/ZIP |
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TELEPHONE #
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CAT’S REGISTERED NAME: | BREED: |
| DATE OF BIRTH: | CAT’S REGISTRATION NUMBER/REGISTRY: | MALE[ ] ALTERED[ ] FEMALE[ ] SPAYED[ ] |
| SIRE’S REGISTRATION # | DAM’S REGISTRATION # | IDENTIFICATION: |
I certify that I am the owner of or agent for this cat, and that the cat presented for examination is the cat described above.
Owner/Agent:
Date:
VETERINARIAN
*Name of Veterinarian*, DVM, Diplomate ACVIM (Cardiology)
*Street Address, City, State, Zip Code*
*Phone Number including Area Code*
DATE OF EXAMINATION:
| ECHOCARDIOGRAM |
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| IVSd cm [ ] mm [
] [ ] M-MODE [ ] 2-D LVIDd [ ] M-MODE [ ] 2-D LVFWd [ ] M-MODE [ ] 2-D IVSs [ ] M-MODE [ ] 2-D LVIDs [ ] M-MODE [ ] 2-D LVFWs [ ] M-MODE [ ] 2-D FS [ ] M-MODE [ ] 2-D EF [ ] M-MODE [ ] 2-D Ao [ ] M-MODE [ ] 2-D LA/Ao [ ] M-MODE [ ] 2-D |
SUBJECTIVE LEFT
ATRIAL SIZE: [ ] NORMAL [ ] MILD ENLARGEMENT [ ] MODERATE ENLARGEMENT [ ] SEVERE ENLARGEMENT SYSTOLIC ANTERIOR MOTION OF THE MITRAL VALVE: [ ] YES [ ] NO IF YES, LV OUTFLOW TRACT FLOW VELOCITY (DOPPLER)
END-SYSTOLIC CAVITY OBLITERATION: [ ] YES [ ] NO PAPILLARY MUSCLES: [ ] NORMAL [ ] ABNORMAL, MODERATE ENLARGEMENT [ ] ABNORMAL, SEVERE ENLARGEMENT |
| COMMENTS:
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| ASSESSMENT / DIAGNOSIS | |
| [ ] NORMAL
(A NORMAL EXAMINATION TODAY DOES NOT MEAN THAT HCM WILL NOT DEVELOP IN THE FUTURE) [ ] EQUIVOCAL [ ] FINDINGS SUSPICIOUS OF MILD OR EARLY HCM [ ] HCM: [ ] MILD [ ] MODERATE [ ] SEVERE |
COMMENTS:
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| RECOMMENDATIONS |
| RECHECK EXAMINATION: [ ] NONE
[ ] 6 MONTHS [ ] 1 YEAR [ ] 2 YEARS [ ] OTHER
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| VETERINARIAN’S
SIGNATURE:
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AREA OF
SPECIALTY:
CARDIOLOGY |
DATE OF EXAMINATION: |