1

IDNO

2

Rate (/min)

3

Rhythm (Sinus = 1, Abnormal = 2)

Specify abnormality rhythm

4

Axis Normal = 1, LAD = 2, RAD = 3, Indeterminate = 4, Extreme RAD = 5

5

Conduction abnormalities? Yes = 1, No = 2

If yes, specify

6

Minnesota coding

7

SV1 + RV5 OR RV6 =

8

R1 AMPLITUDE

SV1 AMPLITUDE

SV2 AMPLITUDE

RV5 AMPLITUDE

SV6 AMPLITUDE

RAVL AMPLITUDE

9

ST-T changes Yes = 1, No = 2

If yes, specify change

Specify leads involved:

V1V2V3 Yes = 1, No = 2

V2V3V4 Yes = 1, No = 2

V4V5V6IaVL Yes = 1, No = 2

II, III, aVF Yes = 1, No = 2

OTHER ST-T changes Yes = 1, No = 2

Specify other ST-T changes

10

Pathological Q Yes = 1, No = 2

If yes, specify leads involved:

V1V2V3 Yes = 1, No = 2

V2V3V4 Yes = 1, No = 2

V4V5V6IaVL Yes = 1, No = 2

II, III, aVF Yes = 1, No = 2

OTHER Pathological Q Yes = 1, No = 2

Specify other Pathological Q

11

QT Duration

QTC duration

12

Other enlargements

RAE Yes = 1, No = 2

LAA Yes = 1, No = 2

RVH Yes = 1, No = 2

13

QRS Durations

V1

V5

V6