Patient Data Entry

Date of Report (mo/day/yr):

1. ID Number:
2. Institution:
3. Date of Birth ( Mo/Day/Yr):

4. Indication for Pacer Implant (Check 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 (Check Choice)

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

8. Comments

Your Name: Your E-Mail Address:

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