10

Arcus senilis Yes = 1, No = 2

11

BP (Systolic/diastolic, mmHg)

SBP1

DBP1

SBP2

DBP2

SBP3

DBP3

12

JVP

JVP Normal Yes = 1, No = 2

JVP Height (cm)

a wave form Normal = 1, Absent = 2, Large = 3

v wave form Normal = 1, Giant = 2

13

Apical impulses:

Character of apical impulse 1 = Normal, 2 = Sustained heaving, 3 = Tapping, 4 = Heaving/diffuse (thrusting), 5 = Feeble, 6 = Absent, 7 = Other

If other, specify

Location of apical impulse 1 = Normal, 2 = Ant. Axillary line, 3 = Axilla, 4 = Other

If other, specify

Specify interspace

14

Heart rate (beats/Min)

15

Heart rhythm 1 = Regular, 2 = Occasional premature beats, 3 = Frequent premature beats, 4 = Atrial fibrillation, 5 = Gallop, 6 = Other

16

If other, specify heart rhythm

17

Heart sounds 1 = Normal, 2 = Distant, 3 = Not heard, 4 = Abnormal

A2 1 = Normal, 2 = Accentuated, 3 = Diminished/absent

P2 1 = Normal, 2 = Accentuated, 3 = Diminished/absent

M1 1 = Normal, 2 = Accentuated, 3 = Diminished/absent

Other Yes = 1, No = 2

If other is yes, specify other

18

Murmurs/thrills

None Yes = 1, No = 2

Aortic systolic Yes = 1, No = 2

Apical systolic Yes = 1, No = 2

Pulm systolic Yes = 1, No = 2

Aortic diastolic Yes = 1, No = 2

Apical diastolic Yes = 1, No = 2

Pulm diastolic Yes = 1, No = 2

Other specify

19

Respiratory findings:

Normal respiratory finding? Yes = 1, No = 2

If no, specify abnormality

20

Abdomen

Normal Yes = 1, No = 2

Specify if no

21

Attending diagnosis? Yes = 1, No = 2

Specify if yes