1. Study ID# and Date

Please complete this questionnaire within 72 hours of an ICD firing. Please request that your physician forward a copy of your complete ICD interrogation report, as well as any other cardiac test results. Reports can be mailed to:

Johns Hopkins Hospital
ARVD Program
600 North Wolfe Street, Carnegie 592
Baltimore, Maryland 21287

Phone: 410-502-7161
Fax: 410-502-9148

* 1. Please enter your Study ID #, instead of your name, to maintain confidentialty. If you do not know your Study ID#, please contact the ARVD office via email, cjames7@jhmi.edu or phone, 443-287-5985.

* 2. Please enter the date you are completing this questionnaire: