Date:

Hospital Name Hosp: East/West Name: PreopDx: Room#: Ht: ___in/cm Wt:___lbs/kg PostopDx: Tape#: Surgeon: Indication: Exam Type: Focused Complete MD: EchoType: TEE EPI TTE Quality: Excellent Good Poor Left Ventricle Mitral Valve Leaflets Doppler Aortic Valve Doppler ................
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