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OCR Page 1 of 2Standard Form 520
Promulgated August 1948
By Bureau of the Budget
Circular A-32
PREVIOUS ECG
CLINICAL RECORD
ELECTROCARDIOGRAPHIC REPORT
YES
NO
CLINICAL IMPRESSION
MEDICATION
EMERGENCY
BEDSIDE
NONE
ROUTINE
AMBULANT
AGE
SEX
RACE
HEIGHT
WEIGHT
125
SIGNAZ URE OF WARD FHYSICIAN
DATE
66
M
3
S'9"
175
80
legin Ohilln AXIS DEVIATION Cup the (QRS)
1-18-51
RHYTHM
RATES
90
Normal
AURIC.
VENT.
INTERVALS
P WAVES
PR 0.20
QRS norma
QT normal
Normal
QRS COMPLEXES
Normal
AT
RS-T SEGMENT
T WAVES
Normal
Normal
PRECORDIAL. LEADS (Specify)
Normal with transition zone at
V-4.
SUMMARY, SERIAL CHANGES, AND IMPLICATIONS:
Normal Electrocardiogram.
NO.
SIGNATURE
TITLE
DATE
ECG
Remaiting
T.W.Mattingly, Colonel MC
19 Jan. '51
15
item AP
?
MOUNT TRACINGS HERE
H
5
I
(Continue on reverse)
PATIENT'S LAST NAME-FIRST JAME MIDDLE NAME
REGISTER NO.
WARD NO.
HST.
u. s. GOVERNNENT PRINTING OFFICE
AMD,
ELECTROCARDIOGRAPHIC REPORT
Standard Form 520
(NAME OF HOSPITAL OR OTHER MEDICAL FACILITY)
16-56209-1
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