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 for Pacing
Atrial Bradycardia
Sinus Bradycardia
Sick Sinus Syndrome
AV Block
2° (Intermittent)
3° (Complete)
AV Node Ablation

 
Special
Tachy/Brady
Atrial Tachy
VVS, CSS
HOCM
CHF
Long QT
Other
     
    Pacemaker Dependent

Concommitent Cardiac Conditions
Atrial Tachycardia
Non-Sinus
A-Fib/Flutter
Other
 
Other
PSVT, SVT
Nodal, Junctional Tachy
Ventricular Tachy
Previous MI
Cardiomyopathy
Valve Disease
Transplant
Other

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