Norwegian Forest Cat HCM DNA Research Project

 

US HCM Screening Form

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PATIENT INFORMATION

OWNER/AGENT NAME:

 

ADDRESS: CITY/STATE/ZIP
TELEPHONE #

 

CATíS REGISTERED NAME: BREED:
DATE OF BIRTH: CATíS REGISTRATION NUMBER/REGISTRY: MALE[ ] ALTERED[ ] FEMALE[ ] SPAYED[ ]
SIREíS REGISTRATION # DAMíS 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

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:

 

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

RECOMMENDATIONS
RECHECK EXAMINATION: [ ] NONE [ ] 6 MONTHS [ ] 1 YEAR [ ] 2 YEARS [ ] OTHER

 

 

VETERINARIANíS SIGNATURE:

 

AREA OF SPECIALTY:

CARDIOLOGY

DATE OF EXAMINATION:

 

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