Certificate of HCM/RCM screening
Patient Information
Owner's name
Cat's registered name
Address
Registration number
Post code/City/State/Country
ID number, microchip or tattoo
Phone (including country code)
Breed of cat
Email
Male
Female
EMS code
Born (year-month-day)
I have informed the examiner of my cats health status and medication if any.
This form must be submitted to Felis Danica together with the request for
pedigrees for any offspring.
Only cats with HCM status “Normal” may be used for breeding *)
Sire
Signature
Dam
Sedated
Examination equipment
Yes, with:
No
On medication
Yes, with:
No
*) applies to male cats of the breed “British Shorthair” see www.felisdanica.dk for further details
Auscultation:
Normal
Gallop
Murmur, characteristics
bpm
I II III IV V VI
Grade:
Pregnant
Systolic
Diastolic
Timing:
Other, describe
Left apex (sternum)
Location:
Weight
kg
Heart rate
Dehydrated
Lactating
IVSd
M-mode
2-D
LVIDd
M-mode
2-D
LVFWd
M-mode
2-D
IVSs
M-mode
2-D
LVIDs
M-mode
2-D
LVFWs
M-mode
2-D
cm
mm
Ao
M-mode
2-D
LA
M-mode
2-D
SF
LA/Ao
Assessment (based on phenotype)
HCM
Date
Examination date (year-month-day)
Examination
Normal
Not altered
Altered
Dynamic
Both
Left Base
Static
Continuous
Other, describe
Subjective left atrial size
Normal
Mild enlargement
Moderate enlargement
Severe enlargement
yes
Systolic anterior motion of the mitral valve
If yes, LV outflow tract flow velocity (Doppler)
End-systolic cavity obliteration
yes
no
Papillary muscles
Normal
Abnormal, moderate enlargement
Abnormal, severe enlargement
Comments
Equivocal
Mild
Moderate
Severe
RCM
Other, describe
Veterinarian's name, clinic's name and address
Veterinarian
Cat's identity verified
Signature
yes
no, describe why not
Date
Felis Danica - Februar 2014 - this form is consistent with form used for the Pawpeds screening programme for HCM/RCM in cats
no