Age : Gender : Male Female

Pre-Test Symptoms : Typical Angina Atypical Angina Non specific Chest Pain

Enter MET : Exercise time minutes : seconds :

Enter Reason for termination : Test criteria achieved ECG changes Patient request Equipment malfunction

Symptoms during test : None Angina self limiting Angina or other cardiac symptoms leading to termination Non-cardiac symptoms

Baseline Heart Rate : Peak Heart Rate : Heart Rate in recovery at 2 minutes :

Baseline ST segment : ST segment at peak exercise(in mm) : ST segment at recovery(in mm) :

ST slope at peak exercise(in mv/sec) : Enter name of Reference Lead :

Baseline Systolic BP : Peak exercise Systolic BP