Date done

Rhythm: Sinusal = 1, Not sinusal = 2

Heart rate

__ __ __bpm

QRS axis: Deviated = 1, Not deviated = 2

QT interval

__ __ __s

Auricular fibrillation: Yes = 1, No = 2

ST segment anomaly: Yes = 1, No = 2

Left ventricular hypertrophy: Yes = 1, No = 2