Insertable Loop Recorder {Serial/Lot Number}  
Model Number   Serial/Lot Number     Implant Date
{Filled in by server}   {Filled in by server}      
/
/
Manufacturer        
  {Product Family -Medtronic Only}

Diagnostic Reason for Monitoring    
Syncope
Presyncope
Dizziness
 
Palpitations
Seizures
Other

Implant Position
Patient Activated
Pectoral
Left Right
Submammary   
Left Right
Subaxillary   
Left Right
Other
 
Auto Activated
Recommended left implant site
Other

Parameter Settings (Fill out areas that apply to this implant)
Memory Settings
21 Min. 42 Min.
   

Patient Activated Events / Auto Activated Events
1 / none    
3 / none    
1 / 13/14    
3 / 5/6    
 
Record
First Last Occuring Events
   
Gain
X1   X2   X4   X8  

Sensitivity
1   2   3   4   5  
6   7   8   9   10  
11   12   13   14   15