ILR {Serial/Lot Number}  
Insertable Loop Recorder
Model Number
  Date of Implant
{filled in by server}    
Manufacturer

Diagnostic Reason for Monitoring    
Syncope
Presyncope
Dizziness
Palpatations
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 Actived Events
1   none
3   none
1   13/14
3   5/6
 
Record
1st. Last Event
   
Gain
X1   X2   X4   X8  

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