Attach #fram13

OMB#: 0925-0216

Expiration Date: xx/xxxx

Physician’s Name	Participant’s Name:
Physician's Mailing Address	Exam Date:
	DOB:
	ID:

________________________________________________________________________

The Heart Study evaluation focuses on cardiovascular disease and is NOT a comprehensive exam. Our research exam does NOT take the place of regular check-ups with a complete physical examination. The following tests are done on a routine basis: Lipids, Glucose, Pulmonary Function, Ankle-brachial BP. Abnormal findings for non-invasive C-V tests will be forwarded separately.

BLOOD PRESSURE:	FIRST READING	SECOND READING
Systolic Blood Pressure
Diastolic Blood Pressure
ECG DIAGNOSIS:
SUMMARY OF SIGNIFICANT HISTORY AND PHYSICAL EXAM:
1. No history or physical exam findings to suggest cardiovascular disease.

OMB No = 0925-0216 3/9/2010 ------------------------------------

HEART STUDY PHYSICIAN