Mv3644 - Medical Examination Report Page 3
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4SECTION E
CARDIOVASCULAR
1. Functional Class
I
II
III
IV
YES NO
2. Does the person have an implantable cardioverter defibrillator? If yes, give implant date:
3. Has the unit discharged since the implant? If yes, describe the person’s condition at the time and date of discharge.
Has this person had any of the following? Please explain any yes answers.
YES NO
4. Cardiovascular surgery and/or other procedures. Describe and give date(s)
5. List all current cardiac symptoms
6. Syncope due to cardiovascular condition:
7. Dyspnea at rest:
8. Fatigue at rest:
9. Have any cardiac tests been conducted (exercise stress test, etc.)? If yes, give procedure(s), date(s), results.
SECTION F
PULMONARY
YES NO
1. Pulmonary Disease? If so, what?
2. Continuous Oxygen Use Required? If so, describe treatment regimen and provide number of liters.
3. Dyspnea at rest?
4. Fatigue at rest?
5. Syncope from cough? Please explain cause and resolution:
6. Provide Pulse Oximetry: Room Air _______________ Oxygen _______________
7. List Pulmonary Function Test Results
8. Does the pulmonary disease prevent activities of daily living? If yes, please identify.
Note: Section G is on the next page (over).
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T585 / MV3644
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