| [604] | 1 | English French  Notes   Complete/Exclude
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 | 2 | TOTAL VPBS,                     
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 | 3 | % OF BTS                        
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 | 4 | TOTAL ECTOPICS,                 
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 | 5 | AVE/HOUR                        
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 | 6 | MAX/HOUR                        
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 | 7 | BLOCKED APCS                    
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 | 8 | BEATS IN RUNS                   
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 | 9 | RUNS SV-T                       
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 | 10 | BEATS IN LONGEST RUN                    
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 | 11 | BEATS FASTEST RUN AT                    
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 | 12 | BTS FASTEST RUN AT                      
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 | 13 | PERFORMED BY:                   
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 | 14 | DATE PERFORMED:                 
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 | 15 | APPROVED BY:                    
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 | 16 | DATE APPROVED:                  
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 | 17 | DATE OF ORIGINAL CONSULT:                       
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 | 18 | INDICATION(S) FOR PERFORMANCE:                  
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 | 19 | PERIPHERAL BLOOD SMEAR:                 
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 | 20 | NO. CELLS COUNTED:                      
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 | 21 | NEUTROPHILS:                    
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 | 22 | ORTHOCHROMATIC NORMOBLASTS:                     
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 | 23 | BANDS:                  
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 | 24 | POLYCHROMATIC NORMOBLASTS:                      
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 | 25 | METAMYELOCYTES:                         
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 | 26 | BASOPHILIC NORMOBLASTS:                         
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 | 27 | MYELOCYTES:                     
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 | 28 | PRONORMOBLASTS:                         
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 | 29 | PROMYLOCYTES:                   
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 | 30 | LYMPHOBLASTS:                   
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 | 31 | MYELOBLASTS:                    
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 | 32 | PLASMA CELLS:                   
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 | 33 | EOSINOPHILS:                    
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 | 34 | MONOCYTES:                      
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 | 35 | BASOPHILS:                      
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 | 36 | HISTIOCYTES:                    
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 | 37 | LYMPHOCYTES:                    
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 | 38 | CELLULARITY:                    
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 | 39 | BLOOD PRESSURE:                         
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 | 40 | VENT RATE:                      
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 | 41 | PR INTERVAL:                    
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 | 42 | INSTRUMENT DX:                  
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 | 43 | CONFIRMATION STATUS:                    
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 | 44 | COMPARISON:                     
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 | 45 | INTERPRETED BY:                         
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 | 46 | Ward/Clinic:                    
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 | 47 | Bronchoscopist:                         
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 | 48 | Fellow:                         
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 | 49 | 2nd Fellow:                     
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 | 50 | SERIAL NUMBER:                  
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 | 51 | ATTENDING PHYSICIAN:                    
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 | 52 | FELLOW-1st:                     
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 | 53 | FELLOW-2nd:                     
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 | 54 | THRESHOLD (VOLTS):                      
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 | 55 | RESISTANCE (OHMS):                      
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 | 56 | P WAVE AMPLITUDE (mV):                  
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 | 57 | PSA USED:                       
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 | 58 | LEAD EXPLANT REASON:                    
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 | 59 | PACING INDICATION:                      
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 | 60 | RISK FACTORS:                   
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 | 61 | PSC STATUS:                     
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 | 62 | SUDDENESS:                      
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 | 63 | COMMENTS AND RECOMMENDATIONS:                   
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 | 64 | INTERPRETED BY:                 
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 | 65 | REVIEWED BY:                    
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 | 66 | HOSPITAL WHERE IMPLANTED:                       
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 | 67 | FIRST SCHEDULED FOLLOW-UP:                      
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 | 68 | NON-MAG RATE                    
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 | 69 | MAGNET RATE                     
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 | 70 | NON-MAG PULSE WIDTH                     
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 | 71 | MAGNET PULSE WIDTH                      
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 | 72 | OTHER INDICATOR                 
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 | 73 | NUMBER OF PULSE GENERATORS:                     
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 | 74 | LAST PREVIOUS IMPLANT:                  
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 | 75 | INCIPIENT MALFUNCTION:                  
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 | 76 | PACING FAILURE:                         
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 | 77 | GENERATOR EXPLANT DATE:                         
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 | 78 | REASON FOR CHANGE:                      
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 | 79 | SUDDENESS:                      
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 | 80 | CALLER:                         
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 | 81 | BASIC RHYTHM:                   
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 | 82 | PERCENT OF PACED BEATS:                         
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 | 83 | PULSE INTERVAL (mSec)                   
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 | 84 | RATE (BPM)                      
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 | 85 | PULSE WIDTH (mSec)                      
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 | 86 | MEASURED LEAD AMPLITUDE (mV)                    
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 | 87 | RATIO (T/L)                     
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 | 88 | THRESHOLD WIDTH                 
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 | 89 | THRESHOLD AMPLITUDE                     
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 | 90 | RATE UPPER LIMIT:                       
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 | 91 | HYSTERESIS:                     
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 | 92 | PULSE WIDTH (ATRIAL mSec):                      
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 | 93 | PULSE WIDTH (VENT. mSec):                       
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 | 94 | SENSITIVITY (ATRIAL mV):                        
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 | 95 | SENSITIVITY (VENT. mV):                         
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 | 96 | REFRACTORY PERIOD (ATRIAL):                     
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 | 97 | REFRACTORY PERIOD (VENT.):                      
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 | 98 | BATTERY VOLTAGE:                        
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 | 99 | BATTERY RESISTANCE:                     
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 | 100 | REASON FOR REPROGRAMMING:                       
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 | 101 | R WAVE AMPLITUDE (mV):                  
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 | 102 | PACING INDICATION:                      
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 | 103 | ICD9 CODE                       
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 | 104 | BACK GROUND INFORMATION                 
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 | 105 | Home phone:                     
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 | 106 | Work phone:                     
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 | 107 | Maritus status:                         
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 | 108 | Employment status:                      
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 | 109 | Occupation:                     
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 | 110 | DEATH - ADMIN.                  
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 | 111 | Lost or death status:                   
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 | 112 | Death date:                     
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 | 113 | Disease activity:                       
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 | 114 | Autopsy available:                      
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 | 115 | Cause of Death:                 
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 | 116 | Chart type:                     
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 | 117 | Observer:                       
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 | 118 | DEC number:                     
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 | 119 | Visit number:                   
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 | 120 | Rheumatic:                      
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 | 121 | Measurements:                   
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 | 122 | SYMMETRICAL ARTHRITIS:                  
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 | 123 | GRIP STRENGTH-LEFT:                     
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 | 124 | SUB-CUTANEOUS NODULES:                  
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 | 125 | GRIP STRENGTH-RIGHT:                    
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 | 126 | SYNOVIAL (BAKER'S) CYST:                        
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 | 127 | SCHOBER TEST (10 cm BASE):                      
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 | 128 | TOPHI:                  
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 | 129 | CHEST EXPANSION:                        
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 | 130 | TENOSYNOVITIS(TENDON RUBS):                     
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 | 131 | OCCIPUT-WALL:                   
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 | 132 | TEMPORAL ARTERY TENDERNESS:                     
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 | 133 | FINGER-TO-PALM CREASE-LEFT:                     
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 | 134 | COSTOCHONDRITIS:                        
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 | 135 | FINGER-TO-PALM CREASE-RIGHT:                    
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 | 136 | INTERINCISOR DISTANCE:                  
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 | 137 | Miscellaneous:                  
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 | 138 | SCHIRMER TEST:                  
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 | 139 | FUNCTIONAL CLASS (ACR):                 
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 | 140 | DISEASE SEVERITY-PAT. ESTIMATE:                 
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 | 141 | DISEASE SEVERITY-PHY. ESTIMATE:                 
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 | 142 | Joint Examination:                      
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 | 143 | Left                    
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 | 144 | Right                   
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 | 145 | FINGERS-DIP                     
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 | 146 | MCPS:                   
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 | 147 | 1st CARPOMETACARPAL:                    
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 | 148 | WRIST:                  
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 | 149 | ELBOW:                  
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 | 150 | SHOULDER:                       
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 | 151 | TMJ:                    
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 | 152 | COSTOCHONDRAL:                  
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 | 153 | SACROILIAC:                     
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 | 154 | HIP:                    
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 | 155 | KNEE:                   
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 | 156 | ANKLE:                  
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 | 157 | MTP:                    
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 | 158 | TOES-PIP:                       
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 | 159 | CERVICAL SPINE:                 
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 | 160 | THORACIC SPINE:                 
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 | 161 | LUMBAR SPINE:                   
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 | 162 | PATIENT PHYSICAL EXAMINATION                    
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 | 163 | Systolic pressure                       
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 | 164 | Diastolic pressure                      
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 | 165 | Uveitis                 
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 | 166 | Lymph Node Enlargement                  
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 | 167 | Cataract                        
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 | 168 | Muscle Tenderness                       
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 | 169 | Iritis                  
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 | 170 | Muscle Weakness - Dital                 
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 | 171 | Oral Ulcers                     
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 | 172 | Hepatomegaly                    
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 | 173 | Rales                   
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 | 174 | Splenomegoly                    
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 | 175 | Pleural Rub                     
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 | 176 | Muscle Weakness - Proximal                      
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 | 177 | Pleural Effusion                        
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 | 178 | Muscle Atrophy                  
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 | 179 | Pericardial Rub                 
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 | 180 | Psychosis                       
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 | 181 | Systolic Murmur                 
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 | 182 | Organic Brain Syndrome                  
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 | 183 | Diastolic Murmur                        
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 | 184 | Motor Neurophathy                       
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 | 185 | Sensory Neurophathy                     
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 | 186 | Heliotrope Eyelids                      
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 | 187 | Telangiectasis                  
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 | 188 | Rash - Malar                    
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 | 189 | Cutaneous Vasculitis                    
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 | 190 | Psoriasis                       
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 | 191 | Periungal Erythema                      
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 | 192 | Rash - Discoid                  
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 | 193 | Keratodermia Blennorrhagica                     
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 | 194 | Rash - JRA                      
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 | 195 | Knuckle Erythema                        
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 | 196 | Palpable Purpura                        
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 | 197 | Digital Ulcers                  
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 | 198 | Sclerodactyly                   
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 | 199 | Nail Pitting                    
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 | 200 | Scleroderma - Extremity                 
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 | 201 | Skin Ulcers                     
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 | 202 | Scleroderma - Generalized                       
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 | 203 | Erythema Nodosum                        
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 | 204 | Morphea                 
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 | 205 | Sysmmetrical Arthritis                  
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 | 206 | Dactylitis                      
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 | 207 | Tophi                   
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 | 208 | Sub-Cutaneous Nodules                   
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 | 209 | Synovial (Baker's) Cyst                 
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 | 210 | Heel Pain                       
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 | 211 | Tenosynovitis (Tendon Rubs)                     
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 | 212 | Temporal Artery Tenderness                      
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 | 213 | Costochondritis                 
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 | 214 | Grip Strength - left                    
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 | 215 | Grip Strength - Right                   
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 | 216 | Schober Test (10 cm Base)                       
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 | 217 | Chest Expansion                 
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 | 218 | Occiput - Wall                  
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 | 219 | Finger-to-Palm Crease - left                    
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 | 220 | Finger-to-Palm Crease - Right                   
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 | 221 | Interincisor Distance                   
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 | 222 | Schirmer Test                   
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 | 223 | Walk Time (50 feet)                     
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 | 224 | Functional Class (ARA)                  
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 | 225 | Disease Severity - Patient Estimate                     
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 | 226 | Disease Severity - Physician Estimate                   
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 | 227 | Fingers - DIPs                  
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 | 228 | Fingers - PIPs                  
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 | 229 | MCPs                    
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 | 230 | First Carpomentacarpal                  
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 | 231 | Wrist                   
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 | 232 | Elbow                   
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 | 233 | Shoulder                        
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 | 234 | Sternoclavicular                        
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 | 235 | Knee                    
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 | 236 | Ankle                   
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 | 237 | Toes - PIP                      
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 | 238 | Cervical Spine                  
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 | 239 | Lumber Spine                    
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 | 240 | Patient History                 
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 | 241 | Head,Eyes,Ears,Nose,Mouth:                      
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 | 242 | BLURRED VISION:                 
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 | 243 | DRY EYES:                       
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 | 244 | Musculosketal:                  
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 | 245 | RINGING IN EARS:                        
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 | 246 | STIFF IN THE MORNING HOW LONG:                  
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 | 247 | HEARING DIFFICULTIES:                   
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 | 248 | JOINT PAIN:                     
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 | 249 | MOUTH SORES:                    
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 | 250 | JOINT SWELLING:                 
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 | 251 | DRY MOUTH:                      
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 | 252 | LOW BACK PAIN:                  
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 | 253 | LOSS,CHANGE IN TASTE:                   
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 | 254 | MUSCLE PAIN:                    
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 | 255 | HEADACHE:                       
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 | 256 | NECK PAIN:                      
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 | 257 | DIZZINESS:                      
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 | 258 | NUMBNESS OR TINGLING:                   
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 | 259 | FEVER:                  
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 | 260 | SWELLING OF LEGS:                       
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 | 261 | NIGHT SWEATS:                   
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 | 262 | WEAKNESS OF MUSCLES:                    
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 | 263 | Chest, Lung, and Heart:                 
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 | 264 | Neurologic and Psychologic:                     
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 | 265 | CHEST PAIN/TAKING DEEP BREATH:                  
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 | 266 | DEPRESSION:                     
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 | 267 | SHORTNESS OF BREATH:                    
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 | 268 | INSOMNIA:                       
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 | 269 | WHEEZING(ASTHMA):                       
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 | 270 | NERVOUSNESS:                    
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 | 271 | SEIZURES OR CONVULSION:                 
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 | 272 | TIREDNESS:                      
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 | 273 | TROUBLE REMEMBERING/THINKING:                   
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 | 274 | Gastrointestinal Tract:                 
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 | 275 | Skin:                   
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 | 276 | LOSS OF APPETITE:                       
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 | 277 | EASY BRUISING:                  
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 | 278 | DIFFICULTY SWALLOWING:                  
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 | 279 | FACIAL SKIN TIGHTENING:                 
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 | 280 | NAUSEA:                 
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 | 281 | HIVES OR WELTS:                 
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 | 282 | HEARTBURN,INDIGESTION,BELCHING:                 
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 | 283 | LOSS OF HAIR:                   
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 | 284 | VOMITING:                       
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 | 285 | ITCHING:                        
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 | 286 | PAIN/DISCOMFORT UPPER ABDOMEN:                  
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 | 287 | RASH:                   
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 | 288 | JAUNDICE:                       
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 | 289 | RASH OVER CHEEKS:                       
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 | 290 | LIVER:                  
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 | 291 | SKIN COLOR CHANGE IN FINGERS:                   
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 | 292 | PAIN/CRAMPS LOWER ABDOMEN:                      
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 | 293 | SUN SENSITIVITY:                        
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 | 294 | DIARRHEA(FREQUENT,WATERY):                      
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 | 295 | CONSTIPATION:                   
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 | 296 | BLK/TARRY STOOL(NOT FROM IRON:                  
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 | 297 | Genitourinary:                  
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 | 298 | Blood:                  
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 | 299 | URINE PROTEIN:                  
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 | 300 | LOW WHITE BLOOD COUNT:                  
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 | 301 | BLOOD IN URINE:                 
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 | 302 | LOW PLATELETS:                  
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 | 303 | ####################    ####################    ####################    
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 | 304 | ####################    ####################    ####################    
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 | 305 | ####################    ####################    ####################    
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 | 306 | ####################    ####################    ####################    
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 | 307 | ####################    ####################    ####################    
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