PATIENT INFORMATION Patient Name: Date of Birth: Phone Number: Address: Health Card Number: Version Code: CARDIAC TESTING Electrocardiogram (ECG) Exercise Stress Test (GXT) 2D Doppler Echocardiography (ECHO)With Contrast Treadmill Stress Echocardiogram (Stress ECHO)With Contrast Dobutamine Stress Echocardiography Speckle-Tracking Echocardiography Cardiac Event Loop Recorder (ELR) Bubble Study Holter Monitor48 hr72 hr14 day30 day Ambulatory Blood Pressure Monitor (ABPM) *not covered by OHIP Indications Palpitations / Arrhythmia Stroke / TIA / Cardiac Source of Embolus Cardiac Murmur / Valvular Heart Disease Shortness of Breath Chest Pain / Known CAD Hypertension / Hypertensive Heart Disease Syncope / Recurrent Presyncope Immediate to high global CAD risk Significant family history of CAD Assess functional capacity prior to structured exercise program (GXT) Other: CARDIOLOGY CONSULTATION Urgent Consultation if Abnormal Test Reason for referral: Physician's Name: Physician's Fax: Physician's Email:
