Cardio Associates of Texas
Joe Smith, M.D., John P. Johnson, M.D., J. Douglas Journeyman, M.D., Steve L. Smitt, M.D.,
Madpa Wppalapati, M.D., Manny Urope, M.D., Jacob Schmaltz, M.D.
111 Some Street, Suite 110
 Dallas, Texas 75252 		710 Someother Street.. Suite 240
Dallas, Texas 75248
Phone: 972-666-7777 Tamara (Scheduling Coordinator) ext., 111 Fax: 972-666-7778
Cardiovascular Testing Worksheet
Patient First Name:    Last Name:   Primary Dr:  
Patient's Phone #  xxx-xxx-xxxx  Diagnosis:  
Patient's Phone # (2)   xxx-xxx-xxxx Referral # required?  
TESTING    Please check appropriate box.
Consultation with Cardiologist - URGENT (within 72 hours).
Consultation with Cardiologist — ELECTIVE (within 1-2 weeks).
Exercise stress Thallium / Cardiolite (Ambulatory)
Adenosine Thallium / Cardiolite (Unable to exercise)
Dobutamine Thallium / Cardiolite (Unable to exercise)
Stress-Echocardiogram (Ambulatory)
Dobutamine Stress-Echocardiogram (Unable to exercise)
Cardiac Echo / Doppler
Holter Monitor
EKG
Carotid Doppler
Abdominal Aortic Sonogram
Ankle Brachial Index
General Guidelines for Stress Testing
I.  High Risk / Intermediate Risk

CAD

 => Thallium Stress Test (ambulatory)
MI  
CHF => Adenosine Thallium (unable to exercise)
Vascular Disease  
Elderly => Dobutamine Thallium (COPD. Asthma)
2 or more Coronary risk factors  
Abnormal EKG  
II.  Intermediate / Low Risk
Young patient, ( < 50 )  
No cardiac history => Stress-Echocardiogram (Ambulatory)
Normal EKG  
< 2 Coronary Risk Factors  
Comments:
Patient List Thursday, July 29, 2010
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