| 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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