English	French	Notes	Complete/Exclude
BURNING ON URINATION:			
LOW RED BLOOD COUNT:			
KIDNEY PROBLEMS:			
Females Only:			
PREGNANT:			
Males Only:			
DISCHARGE FROM PENIS:			
IMPOTENCE:			
OTHER:			
RASH/ULCERS ON PENIS:			
PATIENT LABORATORY INFORMATION			
Aldolase			
Anti-DNA Antibody			
Anti-skeletal muscle			
Alkaline phosphatase			
Anti-RNP			
Urea nitrogen			
Hepatitis B Antibody			
Hepatitis B Antigen			
Cholesterol			
Complement CH50			
Cryoglobulins			
Creatinine			
Complement			
Glucose			
Complement C4			
HLA B27			
Bilirubin, total			
Latex fixation			
Protein, total			
Uric acid			
Salicylate			
UR Glucose			
UR Protein			
RBC/HPF			
WBC/HPF			
Granular/cast/lpf			
Choloride			
WBC/CASTS/LPF			
Bicarbonate			
Creatinine Clearance			
Neutrophil			
Bands			
Lymphs			
Monocytes			
Eosino			
Baso			
Platelet			
Reticulocytes			
Westergren ESR			
Protrhombin time			
Partial thromboplastin			
NARRATIVE HISTORY			
Physical Examination			
General:			
LYMPH NODE ENLARGEMENT:			
UVEITIS/IRITIS:			
MUSCLE TENDERNESS:			
CONJUNCTIVITIS/EPISCLERITIS:			
MUSCLE WEAKNESS-DISTAL:			
CATARACT:			
MUSCLE WEAKNESS-PROXIMAL:			
ORAL ULCERS:			
MUSCLE ATROPHY			
RALES:			
PSYCHOSIS:			
PLEURAL RUB/			
CLINICAL PLEURISY:			
ORGANIC BRAIN SYNDROME:			
PLEURAL EFFUSION:			
MOTOR NEUROPATHY:			
PERICARDIAL RUB/PERICARDITIS:			
SENSORY NEUROPATHY:			
CUTANEOUS VASCULTITIS:			
RASH-MALAR:			
PALPABLE PUPURA:			
RASH-DISCOID:			
SKIN ULCERS:			
RASH-JRA:			
ERYTHEMA NODOSUM:			
RASH-SLE,NON-MALAR:			
PERIUNGAL ERYTHEMA:			
RASH-OTHER:			
HELIOTROPE EYELIDS:			
KNUCKLE ERYTHEMA:			
TELANGIECTASIS:			
SUBCUTANEOUS CALCIFICATIONS:			
SCLERODACTYLY:			
KERATODERMIA BLENNORRHAGICA:			
SCLERODERMA-EXTREMITY:			
DACTYLITIS:			
SCLERODERMA-GENERALIZED:			
NAIL PITTING:			
MORPHEA:			
PSORIASIS:			
DIGITAL ULCERS:			
HEEL PAIN:			
HEALTH ASSESSMENT			
Questionnaire date:			
Study status:			
Drug Study:			
Dressing and Grooming:			
Arising:			
Eating:			
Walking:			
Hygiene:			
Reach:			
Activities:			
Pain Scale:			
II. CLINICAL DATA			
Sex                   			
Age                   			
NYHA functional class       			
Creatinine            			
III. CARDIAC CATHETERIZATION AND ANGIOGRAPHIC DATA			
LVEDP                    			
Lv Contraction Score (from contrast or			
Aortic systolic pressure 			
radionuclide angiogram or 2D echo)			
*PA systolic pressure    			
*PAW mean pressure       			
Grade  Ejection Fraction     Definition			
*patients having right heart cath.			
Range			
Percent left main stenosis 			
Number of other major coronary			
 arteries (LAD,right with PDA,			
 circumflex with marginals)			
 with stenosis(es) => 50%    			
IV. OPERATIVE RISK SUMMARY DATA			
Physician's preoperative 			
estimate of operative 			
V. OPERATIVE DATA			
CABG distal anastomoses:			
number with vein         			
number with IMA          			
Great vessel repair requiring			
Other(not checked above)			
Date of death			
Renal failure requiring			
Repeat cardiopulmonary			
Repeat Cardiopulmonary   			
TIME TEST:			
AGE:  			
WT LBS:			
REF PHYS: 			
ETT PROTOCOL:			
HYPERVENTILATION: 			
TARGET HR: 			
RESTING EKG:			
ONSET CP			
PEAK EX			
SBP/DBP			
ST/SLP			
RPP/1000			
MIN:SEC			
PEAK MPH: 			
     % TARGET HR: 			
TIME ST SEGMENT RETURN TO BASELINE: 			
SIGNIFICANT ARRHYTHMIAS:			
BLOOD PRESSURE CHANGES:			
OTHER EKG CHANGES:			
COMPLICATIONS:			
EKG TECH:			
ATTN PHYS:			
-------------------------------VENTRICULAR STUDY----------------------------			
PREMEDICATION: 			
RECORDING SITE SITE: 			
VENTRICULAR THRESHOLD (mA): 			
REPETITIVE RESPONSES			
VENT. EFF. REFR. PERIOD			
BURST PACING (# REP. RESPONSES): 			
SHORTEST BURST CL: 			
INITIATION SEQUENCE OF V-T: 			
DURATION OF V-T/V-F: 			
V-T CYCLE LENGTH: 			
AXIS: 			
TERMINATION OF VT: 			
PACE OUT CYCLE LENGTH OF V-T: 			
CARDIOVERSION (J): 			
RHYTHM: 			
MEDICATIONS ON DISCHARGE:			
CATHETERIZATION REPORT			
ECHO REPORT			
ECG REPORT			
EP REPORT			
HOLTER REPORT			
RHEUMATOLOGY REPORT			
ETT REPORT			
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Pg. 			
CONFIDENTIAL 			
PROCEDURE DATE/TIME: 			
Select Patient Name or Date of Procedure to Delete:  			
ARE YOU SURE YOU WANT TO DELETE			
Procedure Deleted 			
A-LEAD REPORT			
V-LEAD REPORT			
GENERATOR IMPLANT REPORT			
PACEMAKER SURVEILLANCE REPORT			
COMBINED IMPLANT/LEADS PROCEDURES			
Enter Patient name or Date of Generator Implant: 			
Generator Information....			
Atrial Lead Data....			
Ventricular Lead Data...			
GENERATOR DATA...			
Ventricular			
Atrial			
 Lead data entered for this patient			
 Lead implanted on 			
DEMOGRAPHIC INFORMATION			
ACTIVE PATIENT LIST			
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PACEMAKER ACTIVE PATIENT LIST			
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EAST PSC FOLLOW-UP			
REGISTRY ONLY			
WEST PSC FOLLOW-UP			
Pg.			
GENERATOR IMPLANT DATA			
V AND A LEAD IMPLANT DATA			
MFR MODEL			
SER. NO.			
Enter Patient Name, or Date and Time: 			
SURVEILLANCE PROCEDURES			
       *** SCREEN EDIT ***			
       *** BRIEF EDIT ***			
MCAR(698			
TYPE OF LEAD NOT DEFINED FOR THIS PATIENT IN GENERATOR FILE			
PRESS RETURN TO CONTINUE: 			
PACEMAKER SURVEILLANCE			
PATIENT HAS NO CURRENT GENERATOR IMPLANT LISTED IN GENERATOR FILE			
Entry Deleted			
FORM TRANSFER TO NATIONAL CENTER			
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Transfer Report to : 			
WESTERN PACEMAKER CENTER			
EASTERN PACEMAKER CENTER			
Answer with 'E' for Eastern Center,'W' for Western Center, or 'B' for Both			
BOTH EASTERN AND WESTERN PACEMAKER CENTERS			
TRANSMIT REPORT			
MCR(			
PACEMAKER REPORT TRANSMISSION			
PACEMAKER CENTER REPORT			
REGISTRATION FORM DATA			
 REASON(S) FOR REPORT: 			
TELEPHONE FOLLOW-UP PROVIDED BY: 			
EASTERN PACEMAKER SURVEILLANCE CENTER			
WESTERN PACEMAKER SURVEILLANCE CENTER			
LOCAL VAMC			
PULSE GENERATOR			
MFR: 			
BEGINNING OF LIFE MAGNET RATE: 			
END OF LIFE MAGNET RATE: 			
TELEPHONES:			
IMPLANTING HOSPITAL:			
HOME:   			
WORK: 			
DATE OF INITIAL IMPLANT: 			
RESPONSIBLE PHYSICIAN:			
MCPHYS(			
PULSE GENERATORS INCLUDING PRESENT: 			
             ATRIAL LEAD			
VENTRICULAR LEAD			
ATRIAL LEAD			
MODEL #:     			
SERIAL #:    			
DATE:       			
PART 2			
ALTERNATE CONTACT			
ALTERNATE CONTACT ADDRESS			
TELEPHONE TRANSMITTER:			
MODEL #: 			
IMPLANT PARAMETERS:    ATRIAL LEAD			
THRESHOLD IN VOLTS       			
THRESHOLD IN MAs			
 AT .5 MS PW             			
RESISTANCE AT 5 VOLTS    			
R-WAVE OR P-WAVE			
PSA USED:                			
SURVEILLANCE DATA			
PROGRAMMED SETTINGS			
PULSE WIDTH            			
AMPLITUDE              			
SENSITIVITY            			
REFRACTORY PERIOD      			
LOWER RATE LIMIT: 			
UPPER RATE LIMIT: 			
PACING MODE: 			
CLINIC MEASUREMENTS			
PULSE WIDTH             			
AMPLITUDE               			
RATIO (T/L)             			
THRESHOLD WIDTH         			
THRESHOLD AMPLITUDE     			
CAPTURE                 			
SENSE                   			
RATE NO MAGNET: 			
RATE MAGNET:    			
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