Date        1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   2008 2009

Team    Brown 1 Brown 2 Yellow 1 Yellow 2 Red 1 Red 2 Gray 1 Gray 2

Patient     Last Name      First Name   

FIN #   

Type of CHF    Systolic Diastolic Both                 CAD or H/O MI? Yes No

Aspirin? Yes No            ACE-i/ARB? Yes No              Beta Blocker? Yes No                  Statin? Yes No             Flu Shot? Yes No               Pneumovax? Yes No

Smoking Cessation Counseling? Yes No Not a Smoker

Last ECHO Date        1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   before2006 2006 2007 2008 2009             LVEF greater than 40% less than or equal to 40%

***If any of your responses above is "No," please explain in the comments section.***

Comments:                                                                 Submitted by:     Designation: Resident Intern Observer Volunteer