Pacemaker Follow-Up Evaluation Form
Please complete this form for each post-implant pacemaker follow-up visit. Collects essential medical and device status information.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Follow-Up Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pacemaker Model/Type
*
Device Function Assessment
*
Normal
Abnormal
Requires further evaluation
Patient Symptoms Since Last Visit
*
None
Dizziness
Palpitations
Syncope (Fainting)
Shortness of breath
Other
Physical Exam Findings (if relevant)
Current Cardiac Medications
Recommendations / Next Steps
*
Provider/Clinician Name
*
Submit Evaluation
Should be Empty: