Implantable Pulse Generator
Model Number
Serial Number Date of Implant
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Extensions
Model Number Serial Number Manufacturer Implant Date
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Model Number Serial Number Manufacturer Implant Date
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Previous Device 1 Data
IPG Model No.   IPG Serial No.   IPG Manufacturer
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Previous Device Status   Prior Implant Date
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Device Replaced Date    
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Previous Device 2 Data
IPG Model No.   IPG Serial No.   IPG Manufacturer
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Previous Device Status   Prior Implant Date
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Device Replaced Date    
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Diagnostic Reason for Pacing
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Pacemaker Dependent
 

Was Insertable Loop Recorder used in diagnosis?
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Concommitent Cardiac Conditions
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Parameter Settings
Pacing Mode {filled in by server}
Nominal Settings Yes/No
Mode Switch On/Off
Lower Rate {filled in by server} ppm
Upper Rate {filled in by server} ppm
PVARP {filled in by server} ms
PAV {filled in by server} ms
SAV {filled in by server} ms

 
Rate Adaptive
AV Interval

On/Off
PMT Interven
On/Off
Sensor
ACT/MV/INT
Sleep Function
On/Off