Norwegian Forest Cat HCM DNA Research Project

 

Scandinavian HCM Screening Form

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Hypertrophic Cardiomyopathy Screening Examination Findings

Patient Information
Cat’s registered name Breed
 Date of birth (yyyy-mm-dd)
Cat’s registration number
 Cat’s identification number
 __Male                 __Intact
__Female              __Altered
Sire name
 Dam name
Owner name
 E-mail
 Phone number
Address
I am aware that the results will be retained for the records of the Maine Coon-katten. I authorize the Maine Coon-katten to release all results from this form.

Signature:_______________________________________________ Date:_______________________

Veterinarian Information
Name
 Date of examination
 Equipment make/model

Physical Examination
The cat has to have a permanent identification, tattoo or microchip. Has the cat’s ID been checked?
If yes – The cat’s ID has been checked and corresponds with the ID in the pedigree.		 __Yes  __No
Weight: _______________ kg

Heart rate: _____________ bpm

__Dehydrated __Pregnant

__Lactating __Other; describe:

________________________________

 Auscultation:

__Normal  __Gallop

__Murmur; characteristics:

Grade:__ Dynamic __ Static

Timing: __Systolic __Diastolic __Both __Continuous

Location: __Left apex (sternum) __Left base __Other; describe:

______________________________________________________
Comments

Echocardiogram
IVSd ________                              ___cm ___mm ___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

SF ________

Ao ________                                                          ___M-mode ___2-D

LA ________                                                          ___M-mode ___2-D

LA/Ao ________

Subjective left atrial size:

___Normal
___Mild enlargement
___Moderate enlargement
___Severe enlargement

Systolic anterior motion of the mitral valve: ___Yes ___No

If yes, LV outflow tract flow velocity (Doppler): _________

End-systolic cavity obliteration: ___Yes ___No

Papillary muscles:

___Normal
___Abnormal, moderate enlargement
___Abnormal, severe enlargement
Comments

Assessment / Diagnosis
___Normal (A normal examination today does not mean
that HCM will not develop in the future.)

___Equivocal

___HCM: ___Mild ___Moderate ___Severe

 Comments

Signature
Veterinarian’s signature
 Date and place
A copy of this form shall be sent to: Maine Coon-katten, c/o Kjell Högström, Källstigen 15, SE-757 56 Uppsala, Sweden

2004-02-02

 

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