Cardiology (to be completed for each patient in eval) Demographics Age Select an option30-3940-4950-5960-6970-7980+ Gender MaleFemale Ethnic Origin Select an optionWhiteAsianBlackAfrican AmericanOther if Other Please specify Height Weight Cardiovascular risk factors (if known) Smoking status CurrentFormarNever Dyslipidemia YesNo CAD among 1st degree relatives (< 55 years) YesNo Diagnosed diabetes mellitus YesNo Type 1Type 2Other Diagnosed hypertension YesNo Cardiac Symptoms Typical anginaAtypical anginaNon-anginal chest painDyspnea on exertionOther If Other Please specify CAD-score CAD-score Record ID Measurement successfully completed YesNo If no Please specify Select an optionAmbient noise too highInternal noise too hightIrregular heartbeatInconsistent data analysisOther Other non-invasive testing (if applicable) Type of first other non-invasive test Select an optionstress echoCCTAStress MRINuclear scanOther Outcome PosNegInconclusive Conclusion; patient Select an optionFinished diagnostic progReferred for additional NITReferred for ICA Type of second other non-invasive test Select an optionCCTAstress echoStress MRINuclear scanOther Outcome PosNegInconclusive Conclusion; patient Select an optionFinished diagnostic progReferred for ICA Diagnostic status Additional noninvasive testing deferredNon-significant CAD after cardiac noninvasive testingNo 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? YesNo Medical treatment YesNo Revascularization PCICABG Other, Please specify Management Plan Did the CAD-score impact the patient management plan? YesNo Deferred additional NIT YesNo Escalated NITYesNo Other, Please specify PCP (to be compeletd for each patient in eval) Demographics Age Select an option30-3940-4950-5960-6970-7980+ Gender MaleFemale Ethnic Origin Select an optionWhiteAsianBlackAfrican AmericanOther if Other Please specify Height Weight Cardiovascular risk factors (if known) Smoking status CurrentFormarNever Dyslipidemia YesNo CAD among 1st degree relatives (< 55 years) YesNo Diagnosed diabetes mellitus YesNo Type 1Type 2Other Diagnosed hypertension YesNo Cardiac Symptoms Typical anginaAtypical anginaNon-anginal chest painDyspnea on exertionOther If Other Please specify CAD-score CAD-score Record ID Measurement successfully completed YesNo If Other Please specify Select an optionAmbient noise too highInternal noise too hightIrregular heartbeatInconsistent data analysisOther Treatment Any treatment initiated YesNo Medical treatment YesNo Revascularization PCICABG Other, Please specify Management Plan Did the CAD-score impact the patient management plan? YesNo Deferred additional NIT YesNo Escalated NITYesNo Other, Please specify Was the patient referred to cardiology? YesNo Did the CAD-score help you stratify the patient's risk of CAD? YesNo What other information helped with your determination? LabsEKGStress EKGMedical HistoryCalcium ScoreOther 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: Did the CADScor System System work well with the overall patient flow in your practice? Select an optionStrongly agreeAgreeNeither Agree or DisagreeDisagreeStrongly Disagree Do you feel the CADScor enhances your practice's diagnostic offering? Select an optionStrongly agreeAgreeNeither Agree or DisagreeDisagreeStrongly Disagree Did the CAD-score make your patient more comfortable with your diagnosis or treatment plans?yesno Would you recommend CADScor System to a colleague? yesNo ER/Urgent CarePCP/Internal MedCardiology Why or why not? Any other feedback for improvement? Economic Clinical/Performance Technology
