Custom Form

Cardiology (to be completed for each patient in eval)

Demographics

Age

Height

Feet

Feet Inch

Weight

Gender:

Male Female

Ethnic Origin

Please Specify :

Cardiovascular Risk Factors (if known)

Smoking status:

Current Formar Never

Dyslipidemia

Yes No

CAD among 1st degree relatives (< 55 years)

Yes No

Diagnosed diabetes mellitus

Yes No

Diagnosed hypertension

Yes No

Cardiac Symptoms

Select Option

Typical angina Atypical angina Non-anginal chest pain Dyspnea on exertion Other

Please Specify :

CAD-score

Record ID

Measurement successfully completed

Yes No

Please Specify :

Other Non-Invasive Testing (if applicable)

Type of first other non-invasive test

Outcome

Pos Neg Inconclusive

Conclusion; patient

Type of second other non-invasive test

Outcome

Pos Neg Inconclusive

Conclusion; patient

Diagnostic status

Additional noninvasive testing deferred

Non-significant CAD after cardiac noninvasive testing

No coronary atherosclerosis (no visible atherosclerosis by ICA)

Non-significant CAD (FFR>0.80, instantaneous wave free ratio(iFR)>0.9, or 1-49% diameter stenosis by QCA)

Significant CAD (FFR≤0.80, instantaneous wave free ratio (iFR) ≤0.89 or ≥50% diameter stenosis by QCA)

Treatment

Any treatment initiated

Yes No

Medical treatment

Yes No

Revascularization

Yes No

Please Specify :

Management Plan

Did the CAD-score impact the patient management plan?

Yes No

Deferred additional NIT

Yes No

Escalated NIT

Yes No

Please Specify

Do you want to add a new patient?

Yes No

PCP (to be compeletd for each patient in eval)

Demographics

Age

Height

Feet

Feet Inch

Weight

Gender:

Male Female

Ethnic Origin

Please Specify :

Cardiovascular Risk Factors (if known)

Smoking status:

Current Formar Never

Dyslipidemia

Yes No

CAD among 1st degree relatives (< 55 years)

Yes No

Diagnosed diabetes mellitus

Yes No

Diagnosed hypertension

Yes No

Cardiac Symptoms

Select Option

Typical angina Atypical angina Non-anginal chest pain Dyspnea on exertion Other

Please Specify :

CAD-score

Record ID

Measurement successfully completed

Yes No

Please Specify :

Treatment

Any treatment initiated?

Yes No

Medical treatment

Yes No

Revascularization

Yes No

Please Specify :

Management Plan

Did the CAD-score impact the patient management plan?

Yes No

Deferred additional NIT

Yes No

Escalated NIT

Yes No

Please Specify

Do you want to add a new patient?

Yes No

To be completed once at the end of the evaluation by cardiology or PCP office

Feedback on CPT III code 0716T

Clinic Noninvasive Diagnostic Workflow:

The CADScor System worked well with the overall patient flow in your practice?

Do you feel the CAD-score enhances your practice's diagnostic offering?

Did the CAD-score make your patient more comfortable with your diagnosis or treatment plans?

Yes No

Would you recommend CADScor System to a colleague?

Yes No

ER/Urgent Care PCP/Internal Med Cardiology

Why or why not?

Any other feedback for improvement?

Economic

Clinical/Performance

Technology

Support

Cardiology (to be completed for each patient in eval)

Demographics

Cardiovascular Risk Factors (if known)

Cardiac Symptoms

CAD-score

Other Non-Invasive Testing (if applicable)

Diagnostic status

Treatment

Management Plan

PCP (to be compeletd for each patient in eval)

Demographics

Cardiovascular Risk Factors (if known)

Cardiac Symptoms

CAD-score

Treatment

Management Plan

To be completed once at the end of the evaluation by cardiology or PCP office

Feedback on CPT III code 0716T

Clinic Noninvasive Diagnostic Workflow:

Any other feedback for improvement?

Product

About the product

Resources

Support

References

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Company

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