Hope_Holter_Monitor_Referral-Form

HOLTER SCANNING INFORMATION FORM

HOOK UP DONE AT	DATE OF HOOK UP
FRASER CANYON HOSPITAL	ymd
Surname	First	Address		Phone #

D.O.B. (M/D/YR)	Med. Plan I.D. #			Dept. #

Ordering Dr.’s Name & Initial		MSP #	CC Dr’s Name & Initial	MSP #

Requested Recording Doctor Name & Initial:
Chilliwack General Hospital
Reason for Holter Monitor Test			Medications

Pacemaker Information
OBTAIN THE FOLLOWING FROM THE PATIENT’s “PACEMAKER INFORMATION CARD”
Make:		Model:
Serial Number:		Rate:
Date of Implant:	ymd
Hospital Pacemaker was implanted at:
Does patient attend a pacemaker clinic?		Yes	No
	If yes, where?
Mode:	VVI	DVA	Rate:
	DDD	DDDR	High
	AAI		Low
	V00		HYSTERESIS

Subject: