ECHOCARDIOGRAPHY WORKSHEET

PATIENT NAME: DATE: ID

DATE OF BIRTH: MALE fEMALE TECHNICIAN:

INDICATIONS:
REFERRING PHYS.:

HEIGHT: WEIGHT: BSA: BP: /

M-MODE/2D MEASUREMENTS OTHER:

LVd: RVd: Effusion:

LVs: AO root: Thrombus:

IVSd: LA: Wall Motion

IVSs: AV Cusp: RVSP: mmHg

LVPWd: LVOT: Mitral E/A: / =

LVPWs: EF%: MVP:

AV Cusps Trileaflet: YES NO

DOPPLER MEASUREMENTS

AORTIC PULMONIC TRICUSPID MITRAL

PPG mmHg mmHg mmHg mmHg

MPG mmHg mmHg mmHg mmHg

Velocity m/s m/s m/s m/s

VALVE AREA cm2 cm2 cm2 cm2

PHT ms ms ms ms

REGURGE

COMMENTS: