IPG {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}

Diagnostic Reason
Arachnoiditis
 
Causalgia
 
Peripheral Neuropathy
 
Post-Herpetic Neuralgia
Failed Back Surgery Syndrome
 
Phantom Limb/Stump Pain
 
Peripheral Pain
 
Other Chronic, intractable, pain of trunk or limbs

Implant Position
Left
 
Right
       

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