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

Implant Location
Abdominal
Pectoral
   

Diagnostic Reason
VF Sudden Cardiac Death
 
Atrial Fib/Flutter
 
Post MI (VT, VF)
 
Heart Failure
(Check NYHA Class)
VT Ventricular tachycardia
Supravent, Tachycardia
 
Other
 
I III
II IV

Previous Device Data
Model Number   Serial/Lot Number
 
Device Manufacturer
 
  Prior Implant Date
   
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