ThermEval ACT Examination Submittal Form
Enter patient's name and complete form in the sequence presented:
Patient ID:
Exam Date:  
Use today's date: 
Risk Factors and Symptoms    ? 
M  F  
Patient's current systolic blood pressure: 
Check all applicable factors:   Chronic Hypertension    Cig. Smoker    Heredity     Ethnicity     Abd. Obesity
Check any history of:    Diabetes     Heart Disease    Atrial Fibrillation    Diagnosis of LVH    Previous TIA(s)
Recently experienced symptom(s):   Headache    Dizziness    Speech    Vision    Confusion    Paralysis
Patient Preparation and Examination Conditions    ? 
Was examination performed consistent with TAS Examination Protocol?Yes   No   
Submitter's Comments:  Briefly identify and provide the location of any observations that potentially could influence the objective assessment of the submitted images (e.g., tan, sunburn, artifacts, etc.):
Select and Add the Image Files to Upload: