PATIENT CLINICAL DATA



Date of Report __________ (mo/day/yr)
1. ID Number ______________          
2. Institution    _______________
3. Date of Birth  _____________________ (Mo/Day/Yr)


4. INDICATION FOR PACER IMPLANT   (Circle Appropriate Choices)

	 Congenital heart block
             With Congestive Heart Failure
	     With Syncope
	     With Presyncope
	     With Tachycardias
	     With Other Symptoms (specify ___________________)
	 Surgical Complete heart block
	 Congenital second degree heart block
	 Surgical second degree heart block
	 Congenital sick sinus syndrome
	 Surgical sick sinus syndrome
	 Trifascicular block
	 Bifascicular block
	 Safe pharmacotherapy
	 Other
	 Prolonged QT with Bradycardia
	 Transient Complete heart block
	 Tachycardia Control
5. Associated Structural Heart Disease_____________________
6. Date of Initial Implant ________________ (mo/day/yr)


7. Patient's Clinical Status as of the date of this report

	 Unknown
	 Alive, None or mild symptoms
	 Alive, Moderate or Severe Symptoms
	 Dead - Pacer Related
	 Dead - Not Pacer Related
8.  Comments






                          GENERATOR IMPLANT DATA


Date of Report __________ (mo/day/yr)
1. ID  Number _____________      
2. Institution ____________________
3. Sequence Number of this Generator _____
4. Implant Date ___________ (mo/da/yr)
5. Manufacturer ________________________
6. Model Number _____________
7. Generator Serial Number ________________
8. Programmed Generator Settings when Patient Was Discharged:

	 Mode   _____     AV Interval _________       Rate Response Curve ____
	 Rate   _____     Upper Rate Limit ______     Hysteresis _____


	 Bipolar or Unipolar (circle one)

		                   Ventricle             Atrium
	 Pulse Amplitude          ______               _______
	 Pulse Width              ______               _______
	 Sensitivity              ______               _______
	 Refrac. Period           ______               _______

9. Comments 

















                          GENERATOR EXPLANT DATA



Date of Report __________ (mo/day/yr)

1. ID Number _____________        
2. Institution ____________________
3. Implant Date _________(mo/da/yr)       
4. Explant Date __________(mo/da/yr)
5. Manufacturer _________________       
6. Model Number ________________
7. Generator Serial Number ________________

8. Reason for Explant  (Circle Choice)
	  End of life indicators present
	  Extracardiac pacing
	  Associated with lead change (generator working properly)
	  Generator electronic failure
	  Manufacturer's recall (generator working at explant)
	  Infection
	  Elective upgrade (generator working properly)

9. Generator Characteristics at Explant
	                                PROGRAMMED
	a. Mode                           ______
	b. Rate                           ______
	c. AV Interval                    ______
	d. Upper Rate Limit               ______
	e. Rate Response Curve            ______
	f. Hysteresis                     ______

                                     Ventricle            Atrium	    
	g. Pulse Amplitud             ______              _____
	h. Pulse Width                ______              _____
	i. Sensitivity                ______              _____
 
10. Telemetered Battery Voltage:    ______

11. Comments










                              ELECTRODE DATA


Date of Report __________ (mo/day/yr)

1. ID Number ____________               
2. Institution _____________
3. Implant Date ___________ (mo/da/yr)
4. Manufacturer ________________________
5. Model Number _____________
6. Electrode Serial Number ___________________
7. Is this the patient's first electrode: yes / no (circle one)
8. Site of Implant: atrium / ventricle (circle one)
9. Type of electrode: epicardial / endocardial (circle one)
10. Electrode was: Used / Redundant / Retired (circle one)
11. Threshold at date of reporting:

	At Pulse Width:	_____	_____	_____	_____
	     Voltage	_____	_____	_____	_____
	     Current	_____	_____	_____	_____

12. Resistance measured at 5 volts and 0.5 ms pulse width: _____
13. Sensing Parameters:

	RMS amplitude _____
	Peak to peak amplitude _____
	Slew rate _____


14. Circumstances causing electrode testing  (Circle Choice)       

		 Primary Electrode Placement
		 Cardiac Surgery
		 Revision of lead (reposition, dislodgment)
		 Exploration of pacemaker pocket
		 Generator Replacement

15. Comments