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Intermacs Data Collection Forms Archive

Version 5.1

  • Screening Log
  • Demographics
  • Pre-Implant
  • Implant
  • Implant Discharge
  • 1 Week Follow-Up
  • 1 Month Follow-Up
  • 3 Month Follow-Up
  • 1 Year Post Recovery
  • Adverse Events
  • Patient Transfer Form
  • Withdraw Consent


Version 5.0

  • Screening Log
  • Demographics
  • Pre-Implant
  • Implant
  • Implant Discharge
  • 1 Week Follow-Up
  • 1 Month Follow-Up
  • 3 Month Follow-Up
  • 1 Year Post Recovery
  • Adverse Events
  • Patient Transfer Form
  • Withdraw Consent


Version 4.0

  • Screening Log
  • Demographics
  • Pre-Implant
  • Implant
  • Implant Discharge
  • 1 Week Follow-Up
  • 1 Month Follow-Up
  • 3 Month Follow-Up
  • 1 year Post Recovery
  • Adverse Events
  • Patient Registry Status


Version 3.0

  • Screening
  • Patient Demographics
  • Pre-Implant
  • Implant
  • Implant Discharge
  • 1 Week and 1 Month Follow-Up
  • 3 Month and 6 Month Follow-Up
  • Rehospitalization
  • Infection
  • Neurological Dysfunction
  • Device Malfunction
  • Bleeding
  • Other Adverse Events-AE Reminders
  • Death 
  • Explant
  • Patient Registry Status
  • Functional Capacity
  • QOL Pre-Implant
  • QOL 3 and 6 Month Follow-Up
  • KCCQ
  • Trailmaking


Version 2.3

  • Screening
  • Eligibility
  • Patient Demographics
  • Pre-Implant
  • Implant
  • 1 Week Followup
  • 1 Month Followup
  • 3 Month Followup
  • 6 Month Followup
  • Implant Discharge
  • Reshopitalization
  • AE Infection
  • AE Neurological Dysfunction
  • AE Device Malfunction
  • AE Bleeding
  • Death
  • Explant
  • AE Reminders
  • Functional Capacity
  • Quality of Life-Non Completion
  • Quality of Life
  • Trail Making
 
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