Patient Information
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Referring Physician
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Urgency
Chest Pain Rating
Angina
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Medical History
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Diabetes Hypertension Hyperlipidemia Known CAD Smoker Past Current Strong Family History of Heart Disease
Abnormal ECG Abnormal Stress Test Abnormal Coronary CT History of Myocardial Infarction History of Heart Failure Peripheral Artery Disease
History of COPD Atrial Fibrillation Palpitation History of CABG History of Valvular Surgery Shortness of Breath Obstructive Sleep Apnea
Additional Information / Report Attached
ECG Lab Stress Test
Echo MPI X-Ray
CT MRI Holter 24ABP
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