Aviation Medical Cardiovascular Evaluation Form
Screening form for assessing cardiovascular fitness in aviation medical evaluations.
Full Name
*
First Name
Last Name
Date of Evaluation
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Male
Female
Other
History of Cardiovascular Disease
*
No history
Hypertension
Arrhythmia
Heart Failure
Other
Current Cardiovascular Symptoms
*
None
Chest pain
Palpitations
Shortness of breath
Dizziness
Other
Blood Pressure (mmHg)
*
Heart Rate (bpm)
*
ECG Findings
*
Normal
Abnormal
Not Performed
Examiner Comments
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Should be Empty: