Page 1

1. Outpatient / Inpatient
Mark only one oval.
Outpatient
Inpatient (CTO surgery)
2. Date
Example: 15 December 2012
3. 1. Medical Record

4. 2. Patient Name

5. 3. Sex
Mark only one oval.
Male
Female
6. 4. Age

7. 5. Birthday Date
Example: 15 December 2012
Page 2
8. 6. Diagnosis

9. 7. Height (cm)

10. 8. Weight (kg)

11. 9. Systole (mmHg)

12. 10. Diastol (mmHg)

Page 3
13. 11. Family History of Heart Disease
Mark only one oval.
Yes
No
14. 12. Smoking
Mark only one oval.
Yes
No
15. 13. Diabetes Mellitus
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Yes
No
16. 14. Hipertensi
Mark only one oval.
Ya
Tidak
17. 15. Dislipidemi
Mark only one oval.
Yes
No
Page 4
18. 16. Creatinine

19. 17. Chronic Kidney Disease

Mark only one oval.
Ya
Tidak
20. 18. CHF
Mark only one oval per row.
Tidak

NYHA
21. 19. Prior Cerebrovascular Accident
Mark only one oval.
Yes
No
22. 20. Prior Miocard Infarc
Mark only one oval.
Yes
No
Page 5
23. 21. Prior CABG
Mark only one oval.
Yes
No
Emergency
24. 22. Ejection Fraction (%)

25. 23. Unstable Angina Pectoris

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Yes
No
26. 24. Coronary Artery Disease
Mark only one oval.
Yes
No

27. 25. Ischemic Vessel Treated

Mark only one oval.
Yes
No
Page 6
28. 26. Average Vessel Treated

29. 27. CTO Vessel

30. 28. CTO Length

31. 29. Vessel Intervention

32. 30. Stent Deployed

Page 7
33. 31. No.of Stent

34. 32. DES

35. 33. IVUS

36. 34. Glycoprotein Inhibitor

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None
Moderate
Mild
Severe
37. 35. Calcification

Page 8
38. 36. Ostial Location

39. 37. Procedure Time

40. 38. Fluoroscopy Time

41. 39. Fluoroscopy Dose

42. 40. Mace

Page 9
43. 41. Aortic Dissection

44. 42. Arrhytmia

45. 43. Delayed Tamponade

46. 44. Acute Vessel Oclusion

47. 45. Subacute Vessel Oclution

Page 10
48. 46. Distal Embolization

49. 47. Total Amount Contrast Used

50. 48. Tortuosity

51. 49. In Stent Restenosis

52. 50. Lesion Length

Page 11
53. 51. ISR

54. 52. Side Branch

55. 53. Perforation

Mark only one oval.
Type I
Type II
56. 54. Cardiac Tamponade

57. 55. Cardiac Tamponade

Page 12
58. 56. Non Q Wave MI

59. 57. Q Wave MI

60. 58. Death

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