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PATIENT HISTORY FORM Name: Today's Date: Date of Birth: Weight: Sex: Height: Occupation: Do you have pacemaker? YesNoInternal Stimulator? Restore you Pregnant? YesNoChief Compliant: When did the symptoms
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To fill out you and your pacemaker, follow these steps:
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Gather all the necessary information such as your personal details, medical history, and pacemaker details.
03
Start by filling out your personal details including your name, address, contact information, and emergency contact.
04
Provide accurate information about your medical history, including any previous surgeries, medical conditions, and medications.
05
Specify the details of your pacemaker such as the make, model, and implantation date.
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Answer any additional questions related to your pacemaker or related medical conditions.
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Review the filled-out form for any errors or missing information.
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Sign and date the form to confirm its accuracy and completeness.
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Submit the filled-out form to the relevant healthcare provider or organization.

Who needs you and your pacemaker?

01
People who require pacemakers may include those with certain heart conditions such as bradycardia (slow heart rhythm) or arrhythmias (irregular heartbeats).
02
Individuals who experience symptoms such as dizziness, fatigue, fainting, or shortness of breath due to heart rhythm abnormalities may need a pacemaker.
03
The decision to implant a pacemaker is made by a healthcare professional after thorough examination and diagnosis.
04
It is important to consult with a cardiologist or healthcare provider to determine if you need a pacemaker.
05
Only individuals who have been diagnosed with specific heart conditions and have been recommended a pacemaker by a healthcare professional should consider getting one.
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