Case Summary Form
Name of the CardioDx employee submitting this form:
Name of the clinician who evaluated the case:
Date this form was completed:
University/hospital affiliation of the clinician:
Practice where patient was seen:
Name:
Address:
Phone:
Email:
Case Details:
Age:
Name:
Address:
Phone:
Email:
Gender:
Presenting Symptoms:
Pertinent PMH:
Corus CAD score:
Other Cardiac tests and evaluations:
Findings/Outcomes/Disposition:
Brief Summary (in less than 100 words):
Suggested journals and presentation venues?
To retrieve Corus CAD report, please specify patient’s name and DOB
Do you have source documentation for other tests done for this patient? ☐ yes
☐ no
Do you have patient’s written or oral consent to present or publish this case? ☐ yes
FRM-000298 Rev0
☐ no