Form 3: Routine ICD Follow-Up Questionnaire

1. Study ID# and Date

 
Please complete this questionnaire after each routine ICD interrogation. 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
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1. Please enter your Study ID #, instead of your name, to maintain confidentiality. If you do not know your Study ID#, please contact the ARVD office via email, cjames7@jhmi.edu or phone, 443-287-5985.
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2. Please enter the date of your interrogation:
MM DD YYYY
Date
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