English	French	Notes	Complete/Exclude
TOTAL VPBS,			
% OF BTS			
TOTAL ECTOPICS,			
AVE/HOUR			
MAX/HOUR			
BLOCKED APCS			
BEATS IN RUNS			
RUNS SV-T			
BEATS IN LONGEST RUN			
BEATS FASTEST RUN AT			
BTS FASTEST RUN AT			
PERFORMED BY:			
DATE PERFORMED:			
APPROVED BY:			
DATE APPROVED:			
DATE OF ORIGINAL CONSULT:			
INDICATION(S) FOR PERFORMANCE: 			
PERIPHERAL BLOOD SMEAR:			
NO. CELLS COUNTED: 			
NEUTROPHILS: 			
ORTHOCHROMATIC NORMOBLASTS: 			
BANDS: 			
POLYCHROMATIC NORMOBLASTS: 			
METAMYELOCYTES: 			
BASOPHILIC NORMOBLASTS: 			
MYELOCYTES: 			
PRONORMOBLASTS: 			
PROMYLOCYTES: 			
LYMPHOBLASTS: 			
MYELOBLASTS: 			
PLASMA CELLS: 			
EOSINOPHILS: 			
MONOCYTES: 			
BASOPHILS: 			
HISTIOCYTES: 			
LYMPHOCYTES: 			
CELLULARITY: 			
BLOOD PRESSURE: 			
VENT RATE: 			
PR INTERVAL: 			
INSTRUMENT DX: 			
CONFIRMATION STATUS: 			
COMPARISON: 			
INTERPRETED BY: 			
Ward/Clinic: 			
Bronchoscopist: 			
Fellow: 			
2nd Fellow: 			
SERIAL NUMBER: 			
ATTENDING PHYSICIAN: 			
FELLOW-1st: 			
FELLOW-2nd: 			
THRESHOLD (VOLTS):			
RESISTANCE (OHMS): 			
P WAVE AMPLITUDE (mV): 			
PSA USED: 			
LEAD EXPLANT REASON: 			
PACING INDICATION:			
RISK FACTORS: 			
PSC STATUS: 			
SUDDENESS:  			
COMMENTS AND RECOMMENDATIONS: 			
INTERPRETED BY:			
REVIEWED BY:			
HOSPITAL WHERE IMPLANTED: 			
FIRST SCHEDULED FOLLOW-UP: 			
NON-MAG RATE			
MAGNET RATE			
NON-MAG PULSE WIDTH			
MAGNET PULSE WIDTH			
OTHER INDICATOR			
NUMBER OF PULSE GENERATORS: 			
LAST PREVIOUS IMPLANT: 			
INCIPIENT MALFUNCTION: 			
PACING FAILURE: 			
GENERATOR EXPLANT DATE: 			
REASON FOR CHANGE: 			
SUDDENESS: 			
CALLER: 			
BASIC RHYTHM: 			
PERCENT OF PACED BEATS: 			
PULSE INTERVAL (mSec)			
RATE (BPM)			
PULSE WIDTH (mSec)			
MEASURED LEAD AMPLITUDE (mV)			
RATIO (T/L)			
THRESHOLD WIDTH			
THRESHOLD AMPLITUDE			
RATE UPPER LIMIT: 			
HYSTERESIS: 			
PULSE WIDTH (ATRIAL mSec): 			
PULSE WIDTH (VENT. mSec): 			
SENSITIVITY (ATRIAL mV): 			
SENSITIVITY (VENT. mV): 			
REFRACTORY PERIOD (ATRIAL): 			
REFRACTORY PERIOD (VENT.): 			
BATTERY VOLTAGE: 			
BATTERY RESISTANCE: 			
REASON FOR REPROGRAMMING: 			
R WAVE AMPLITUDE (mV): 			
PACING INDICATION: 			
ICD9 CODE			
BACK GROUND INFORMATION			
Home phone:			
Work phone:			
Maritus status: 			
Employment status: 			
Occupation:			
DEATH - ADMIN.			
Lost or death status:			
Death date:			
Disease activity:			
Autopsy available:			
Cause of Death:			
Chart type:			
Observer:			
DEC number:			
Visit number:			
Rheumatic:			
Measurements:			
SYMMETRICAL ARTHRITIS:			
GRIP STRENGTH-LEFT:			
SUB-CUTANEOUS NODULES:			
GRIP STRENGTH-RIGHT:			
SYNOVIAL (BAKER'S) CYST:			
SCHOBER TEST (10 cm BASE):			
TOPHI:			
CHEST EXPANSION:			
TENOSYNOVITIS(TENDON RUBS):			
OCCIPUT-WALL:			
TEMPORAL ARTERY TENDERNESS:			
FINGER-TO-PALM CREASE-LEFT:			
COSTOCHONDRITIS:			
FINGER-TO-PALM CREASE-RIGHT:			
INTERINCISOR DISTANCE:			
Miscellaneous:			
SCHIRMER TEST:			
FUNCTIONAL CLASS (ACR):			
DISEASE SEVERITY-PAT. ESTIMATE:			
DISEASE SEVERITY-PHY. ESTIMATE:			
Joint Examination:			
Left			
Right			
FINGERS-DIP			
MCPS:			
1st CARPOMETACARPAL:			
WRIST:			
ELBOW:			
SHOULDER:			
TMJ:			
COSTOCHONDRAL:			
SACROILIAC:			
HIP:			
KNEE:			
ANKLE:			
MTP:			
TOES-PIP:			
CERVICAL SPINE:			
THORACIC SPINE:			
LUMBAR SPINE:			
PATIENT PHYSICAL EXAMINATION			
Systolic pressure			
Diastolic pressure			
Uveitis			
Lymph Node Enlargement			
Cataract			
Muscle Tenderness			
Iritis			
Muscle Weakness - Dital			
Oral Ulcers			
Hepatomegaly			
Rales			
Splenomegoly			
Pleural Rub			
Muscle Weakness - Proximal			
Pleural Effusion			
Muscle Atrophy			
Pericardial Rub			
Psychosis			
Systolic Murmur			
Organic Brain Syndrome			
Diastolic Murmur			
Motor Neurophathy			
Sensory Neurophathy			
Heliotrope Eyelids			
Telangiectasis			
Rash - Malar			
Cutaneous Vasculitis			
Psoriasis			
Periungal Erythema			
Rash - Discoid			
Keratodermia Blennorrhagica			
Rash - JRA			
Knuckle Erythema			
Palpable Purpura			
Digital Ulcers			
Sclerodactyly			
Nail Pitting			
Scleroderma - Extremity			
Skin Ulcers			
Scleroderma - Generalized			
Erythema Nodosum			
Morphea			
Sysmmetrical Arthritis			
Dactylitis			
Tophi			
Sub-Cutaneous Nodules			
Synovial (Baker's) Cyst			
Heel Pain			
Tenosynovitis (Tendon Rubs)			
Temporal Artery Tenderness			
Costochondritis			
Grip Strength - left			
Grip Strength - Right			
Schober Test (10 cm Base)			
Chest Expansion			
Occiput - Wall			
Finger-to-Palm Crease - left			
Finger-to-Palm Crease - Right			
Interincisor Distance			
Schirmer Test			
Walk Time (50 feet)			
Functional Class (ARA)			
Disease Severity - Patient Estimate			
Disease Severity - Physician Estimate			
Fingers - DIPs			
Fingers - PIPs			
MCPs			
First Carpomentacarpal			
Wrist			
Elbow			
Shoulder			
Sternoclavicular			
Knee			
Ankle			
Toes - PIP			
Cervical Spine			
Lumber Spine			
Patient History			
Head,Eyes,Ears,Nose,Mouth:			
BLURRED VISION:			
DRY EYES:			
Musculosketal:			
RINGING IN EARS:			
STIFF IN THE MORNING HOW LONG:			
HEARING DIFFICULTIES:			
JOINT PAIN:			
MOUTH SORES:			
JOINT SWELLING:			
DRY MOUTH:			
LOW BACK PAIN:			
LOSS,CHANGE IN TASTE:			
MUSCLE PAIN:			
HEADACHE:			
NECK PAIN:			
DIZZINESS:			
NUMBNESS OR TINGLING:			
FEVER:			
SWELLING OF LEGS:			
NIGHT SWEATS:			
WEAKNESS OF MUSCLES:			
Chest, Lung, and Heart:			
Neurologic and Psychologic:			
CHEST PAIN/TAKING DEEP BREATH:			
DEPRESSION:			
SHORTNESS OF BREATH:			
INSOMNIA:			
WHEEZING(ASTHMA):			
NERVOUSNESS:			
SEIZURES OR CONVULSION:			
TIREDNESS:			
TROUBLE REMEMBERING/THINKING:			
Gastrointestinal Tract:			
Skin:			
LOSS OF APPETITE:			
EASY BRUISING:			
DIFFICULTY SWALLOWING:			
FACIAL SKIN TIGHTENING:			
NAUSEA:			
HIVES OR WELTS:			
HEARTBURN,INDIGESTION,BELCHING:			
LOSS OF HAIR:			
VOMITING:			
ITCHING:			
PAIN/DISCOMFORT UPPER ABDOMEN:			
RASH:			
JAUNDICE:			
RASH OVER CHEEKS:			
LIVER:			
SKIN COLOR CHANGE IN FINGERS:			
PAIN/CRAMPS LOWER ABDOMEN:			
SUN SENSITIVITY:			
DIARRHEA(FREQUENT,WATERY):			
CONSTIPATION:			
BLK/TARRY STOOL(NOT FROM IRON:			
Genitourinary:			
Blood:			
URINE PROTEIN:			
LOW WHITE BLOOD COUNT:			
BLOOD IN URINE:			
LOW PLATELETS:			
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