Infusion Pump {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}

Drug Indicated
Morphine   Baclofen   Floxuridene
Other    

Calibration Constant/Flow Rate
mg/ml  

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/Disease
Other
 
Type of Cancer:
Liver, Metastatic or Primary
Renal Cell
Prostate
Other

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