Lead {Serial/Lot Number}  
Tachy Lead Model Number   Date of Implant Same date as
{filled in by server}   IPG/ICD
Location
Right Atrium   Superior Vena Cava
Right Ventricle   Coronary Sinus
Left Atrium    
Left Ventricle    

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

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
 
Device Replaced Date    
   

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
 
Device Replaced Date