Model Number Serial/Lot Number Manufacturer Date of Implant
{filled in by server} {filled in by server}   {filled in by server}   {filled in by server}
Location
{filled in by server}
Lead measurements as measured by PSA or equivalent
Pacing/Sensing
Pulse Width Voltage Current
{filled in by server} ms   {filled in by server} V   {filled in by server} ma
    Impedance Sensing
    {filled in by server} ohms P-Wave {filled in by server} mV
Previous Device Data
Model Number Serial Number Manufacturer Prior Implant Date
{filled in by server} {filled in by server} {filled in by server} {filled in by server}