Cardiac Imaging Annotation Form
Structured annotation of cardiac imaging studies for clinical or research purposes.
Patient Initials
*
Study Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Imaging Modality
*
Please Select
Echocardiography
Cardiac MRI
Cardiac CT
Nuclear Cardiology
Other
Primary Indication for Study
*
Please Select
Assessment of cardiac function
Evaluation of ischemia
Structural heart disease
Arrhythmia evaluation
Other
Image Quality
*
Excellent
Good
Adequate
Poor
Anatomical Structures Evaluated
*
Left Ventricle
Right Ventricle
Left Atrium
Right Atrium
Aortic Valve
Mitral Valve
Tricuspid Valve
Pulmonary Valve
Other
Presence of Cardiac Abnormalities
*
Yes
No
Uncertain
Type of Abnormality (if present)
Wall motion abnormality
Valve disease
Chamber enlargement
Pericardial effusion
Mass/tumor
Other
Severity Grading (if abnormality present)
Please Select
Mild
Moderate
Severe
Not applicable
Reviewer Name/Initials
*
Additional Comments or Observations
Submit Annotation
Should be Empty: