Cardiac Pacemaker Recommendation Form
Please complete this form to provide essential information for evaluating the need for a cardiac pacemaker recommendation.
Patient Full Name
*
First Name
Last Name
Patient Age
*
Patient Sex
*
Male
Female
Other
Main Symptom(s)
*
Syncope (fainting)
Dizziness or lightheadedness
Palpitations
Fatigue
Chest discomfort
Shortness of breath
No symptoms
Other
History of Cardiac Arrhythmia
*
Yes
No
Unknown
ECG Findings (if available)
*
Sinus bradycardia
Complete heart block (3rd degree AV block)
Mobitz type II AV block
Atrial fibrillation with slow ventricular response
Bundle branch block
Normal ECG
ECG not available
Heart Rate (bpm, at rest)
*
Relevant Past Medical History
*
Coronary artery disease
Heart failure
Valvular heart disease
Congenital heart disease
Hypertension
Diabetes
None of the above
Other
Current Cardiac Medications
*
Physical Activity Tolerance
*
No limitation (normal activity)
Mild limitation (can do light activity)
Moderate limitation (difficulty with moderate activity)
Severe limitation (symptoms at rest or minimal activity)
Submit Recommendation Form
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