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Have you had any of the following tests If yes when and what were the results EKG Yes No Normal Abnormal Unknown Echocardiogram Echo Doppler Test Heart Catherization Holter Monitor Thallium Stress/ Treadmill 4. Mailing Address 175 Scott Swamp Road PO Box 4058 Farmington CT 06034-9863 Fax 860 674-2862 Supplement to ConnectiCare SOLO Application HEART MURMUR/ MITRAL VALVE PROLAPSE QUESTIONNAIRE Name of primary applicant. ID/SSN. Name of person related to condition. 1. Give exact diagnosis. Date...
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