The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

jzcrYzA5GSgD9tFt6AavSWjWk7BPs3U7zmf8qhygh59Zvy5VNy8t2BzFRNRE5IIAgxnVRdHHiurQRgSsNVbgt4U5eyNdct92QRWqcBPTYNHDYkZFhoNTRoCsfEsPg7Tm

ICD Firing

Please complete the survey below when you receive therapy from your device. Contact Crystal Tichnell at ctichnell@jhmi.edu with any questions.

Thank you!

Please enter your First and Last Name

* must provide value

Please enter your year of birth.

* must provide value

Date of ICD Firing/ATP (mm//dd/yyyy)

M-D-Y

Time of ICD Shock/ATP (please also indicate AM or PM)

How many shocks did you feel?

Do you know or has your doctor mentioned if the shock/ATP was:

Appropriate

Inappropriate

I don't know

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List all the medications and their dosages that you took in the last 24 hours:

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Was there any change made in your medications in the last week?

Yes

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If there was a change in your medications within the past week, please explain:

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Were any of your usual medications not taken in the last 24 hours before the ICD firing?

Yes

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If you did not take your usual medications in the last 24 hours prior to your ICD firing, please explain:

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Please describe the specific activity you were engaged in at the time of ICD firing? (eg, watching TV, grocery shopping, etc...)

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Did you require evaluation in the ER or hospitalization due to the ICD shocks?

Yes

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If you required evaluation in the ER or hospitalization due to your ICD shocks, please list the name of the medical facility.

In the last 1 month prior to your shock, has your exercise pattern:

Increased

Decreased

Stopped

No change

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In the last 1 week prior to your shock, has your exercise pattern:

Increased

Decreased

Stopped

No change

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.