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HCM/RCM screening within health programme
Participating clubs: see httpJ/www.pawpeds.com/healthprogrammes/hcmclubs.html
Visit httpJ/www.pawpeds.com/healthprogrammes/ for more information
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Owner's nâme
Patient lnformation
FALLER CHANTAL
Çat's registered name
Address
LEO DES BORDS DU RHIN
49 QUAI DES ALPES
Post code/CiÿState
Registration number
LOOF 2015 201350
67000 STRASBOURG
lD number, microchip or tattoo
Country
250269606516410
FRANCE
Breed of cat
Phone (including country code)
NORWEGIAN FOREST CAT
0033620978433
!-lAhered
:mall
Not altered
$Male
-l
Female
[email protected]
Born (year-monih-day)
I have reâd PawPeds' instructions for HCM screening and are aware that I must
inform the examiner aboui my cats health status and if it is on medication. I am
aware thât thê rebults will be retainêd for the remrds of PawPeds I âuthorizc
2015-07-02
si16
PawPeds to publicly release all results from this form.
Signature
TITRAN'S PLATO
Dam
Examination
Sedated
n
ation
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with:
Date
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Auscultation:
Weight
E[ttormat
kg
41-o
Heart rate
E
bpm
IDehydrated f]Pregnant
! Lactating I
IIVSd
LVIDd
Otn"r, describe
ÿ''ü [c, p,,
4\ü
LVFWd
ÿ,r
lVSs
é,.7
LVIDs
,'{tO
LVFWs
1,)
,'
Grade: I ll lll lV V Vl
I Dynamic Estrti"
Timing: Esystotic ÜDiastotic IaoÛ'
E Continuous
Location: n I-ett apex (sternum) E tett gase Eotn"r, describe
pna-mooe
$rra-mooe
Qtr,t-moae
Ez-o
Ez-o
fJz-o
Eu-mode nz-o
Eltr"t-moae
J^-7
Dcattop
ùturmur, charâcteristics
ffiu-moae Ez-o
Ez-o
Subjective left atrial size
I
!
frllitO
enlargemènt
Moderate enlargement
Isevere
enlargement
Systolic anterior motion of the mitral valve
K,t'
IJM-mode lÀz-o
flu-mooe E[z-o
LA
LA/Ao
/,,\
Assessment (based on phenotype)
ny""
lf yes, LV outflow tract flow velocity (DopÉler)
End-systolic cavity obliteration
SF
Ao
nyes M'o
Papillary muscles
@§ormal
f]
I
Abnormal, moderate enlargement
Abnormal, severe enlargement
Commenis
E[ruormat IEquivocal
!ncrrl !rritito IModerate
flncn,t
E otn"r,
nsevere
describe
name, clinic's name and address
Veterinarian
PawPeds' examination instructions has been followed
Cat's identity verified Elyes
no, describe why not
!
"n"'frr,/"bt
Date
,t ,tr. t7 .," .t,
,/ b/t't.!(rt/ >,t !,!,
Ç
j
,,1{telntierpraxis
Andreas Kirsch
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ilÂ
f,l,'
u. iieimiiere
;T,\ .rr: Ii'r-.r:ii lieCirui ,' Kardiui*Eie
d : ^; i'.':t ç:',.!:;:it 1, 7 ti7 3 P{orlheiin
For registration of the result, the veterinarian shall send a copy of this form to:
PawPeds, c/o Olsson, Angsmyrvâgen 1 Bâsna, SE-781 95 BORLANGE, Sweden
Rev 1.13 (en) 201'l-01-07
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Examination eouioment
[Yes, with:
!Yes,
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FLORADORA DES BORDS DU RHIN
Exam
,
Etrno