Lead Model Number   Date of Implant Same date as
Lead Model #3  
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Primary Device
Location
RA RV SVC LA LV CS

Lead measurements as measured by PSA or equivalent
Pacing/Sensing
Pulse Width   Voltage   Current
ms   V   ma
    Impedance   Sensing
    ohms   P-Wave mV

Defibrillation Lead Measurements
High Voltage Pathway   DFT/LED   Impedance
  J   ohms

Previous Device Data (Complete if the following information for devices being replaced)
Lead Model No.   Lead Serial No.   Lead Manufacturer
   
Previous Device Status   Prior Implant Date
 
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Device Replaced Date    
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  This device replaces more than one previously implanted device