Hosted Demo

Heart Disease Intake Form

Structured clinical inputs grouped for fast data entry.

Demographics

Age

Sex

Ethnicity group

Height (cm)

Weight (kg)

BMI

Lifestyle Risk Factors

Smoking status

Pack-years

Alcohol use

Physical activity level

Past Medical History

HypertensionDiabetes MellitusDyslipidemiaFamily history of CADPrior MIPrior PCI/CABGStroke historyChronic Kidney Disease

Current Medications

StatinsAntiplateletsBeta blockersACE inhibitors / ARBsInsulinOral hypoglycemics

Vitals

Resting Systolic BP

Resting Diastolic BP

Heart rate

Waist circumference (cm)

Oxygen saturation (%)

Laboratory Values

Total Cholesterol

LDL

HDL

Triglycerides

HbA1c

Fasting blood glucose

Serum creatinine

eGFR

High-sensitivity CRP

Lipoprotein(a)

ApoB

BNP

ECG Variables

Resting ECG interpretation

ST depression

ST slope

T-wave inversion

QT interval

Echocardiography

Ejection fraction (%)

Regional wall motion abnormality

Left ventricular hypertrophy

UCI Legacy Fields

Chest pain type

Fasting blood sugar > 120 mg/dl

Max heart rate achieved

Exercise induced angina

Major vessels (0-3)

Thalassemia

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