IPG {Serial/Lot Number}  
Implantable Pulse Generator
Model Number
  Date of Implant
{filled in by server}    
IPG Manufacturer

Extensions
Model Number   Serial/Lot Number   Manufacturer   Implant Date
     
Model Number   Serial/Lot Number   Manufacturer   Implant Date
     

Previous Device Data (Complete if the following information for devices being replaced)
IPG Model No.   IPG Serial No.   IPG Manufacturer
   
Previous Device Status   Prior Implant Date
 
Device Replaced Date    
   

Previous Device Data (Complete if the following information for devices being replaced)
IPG Model No.   IPG Serial No.   IPG Manufacturer
   
Previous Device Status   Prior Implant Date
 
Device Replaced Date    
   

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

Pacemaker Dependent
   
Was Insertable Loop Recorder used in diagnosis?
Yes
No
 
Special
Tachy/Brady
Atrial Tachy
WS, CSS
HOCM
CHF
Long QT
Other

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

Parameter Settings (Fill out areas that apply to this implant)
Pacing Mode
Nominal Settings
Yes No
Mode Switch
On Off
Lower Rate ppm
Upper Rate ppm
PVARP ms
PAV ms
SAV ms

 
Rate Adaptive
AV Interval

On Off
PMT Interven

On Off
Sensor


ACT MV INT
Sleep Function

On Off