1. How would you characterize this patient’s risk of suffering a fatal or nonfatal MI in the next 14 days?
□ Low risk	□ Moderate risk	□ High risk
2. How would you characterize this patient’s chest pain?
□ Noncardiac	□ Possibly cardiac	□ Definitely cardiac
3. What is the likelihood that this patient would benefit from a cardiac catheterization procedure?
□ Very unlikely	□ Somewhat unlikely	□ Unsure
□ Somewhat likely	□ Very likely
4. Estimate the probability that this patient has a significant CAD (or stenosis >70%).
□ Very unlikely	□ Somewhat unlikely	□ Unsure
□ Somewhat likely	□ Very likely
5. If you decide to not refer this patient for catheterization, would you order any further tests?
□ Yes	□ No
If so, which of the following?
□ Stress test	□ Stress test and thallium
□ Cardiac function assessment	□ Other ___________________
6. How much does the patient’s preference influence your decision to refer them for catheterization?
□ Not much at all	□ Not a lot	□ Unsure
□ A fair amount	□ To a great extent
7. Do you need any more information to make your decision regarding further testing?
□ Yes	□ No
If so, what information would you require? __________________
_____________________________________________________.