Pump {Serial/Lot Number}  
Pump Model Number   Date of Implant
{filled in by server}    
Manufacturer

Accessories
Model Number   Serial/Lot Number   Manufacturer
   
Model Number   Serial/Lot Number   Manufacturer
   

Drug Indicated
Morphine   Baclofen Injection   Floxuridene
Other    

Diagnostic Indication for Use
Malignant Pain
Type of Cancer

Primary site of pain:
Spine/Back
Abdominal/Visceral
Thoracic
Extremity
Head/Neck
Pelvic
Other

  Non-Malignant Pain
Cause:
Failed Back Syndrome
RSD/Causalgia (CRPS)
Osteoporosis
Joint Pain/Arthritis
Post-Herpetic Neuralgia
Peripheral Neuropathy
Other
Intractible Spasticity   Cancer Chemotherapy
Cause:
Cerebral Palsy
Brain Injury
Multiple Sclerosis
Spinal Cord Injury
Spinal Cord Disease
Other
 
Type of Cancer:
Liver, Metastatic or Primary
Prostate
Renal Cell
Other

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