PLACE LABEL HERE

WATCHMAN DEMOGRAPHICS / CRITERIA

Name: ______

DOB: ______Phone: ______

Referring Physician: ______Phone: ______Fax: ______

Primary Cardiologist: ______Phone: ______Fax: ______

Inclusion Criteria: (All must be answered yes or patient is not eligible)

Non-Valvular Atrial Fibrillation q Yes q No (Verify AF 1st documented): ______

CHA2DS2 VASC q CHF q HTN q 65-74 q 75 (2) q DM q Female q CVA (2) q Vascular

Increased Risk for Stroke based on CHA2DS2 VASC Documented q HAS-BLED Score: _____ q CHA2DS2 VASC Score: _____

Short Term Contraindication to Warfarin q Yes q No Anticoagulant:

Long Term Contraindication to Warfarin q Yes q No q None q Warfarin

Reason to seek Alternative q Yes q No q Apixaban q Dabigatran

Able to take Aspirin q Yes q No q Endoxaban q Rivaroxaban

Able to take Plavix (clopidogrel) q Yes q No

Compliant: q Yes q No

Shared Decision Documentation with independent Non Interventional Physician: q Yes q No

Exclusion Criteria: (All must be answered no or patient is not eligible)

History of Non-Compliance q Yes q No Prior atrial septal repair or device q Yes q No

Current Thrombus q Yes q No Other anticoagulation indication (DVT) q Yes q No

Mechanical Valve q Yes q No Women pregnant or planning to become q Yes q No

TEE: ______LAA Type ______#Lobes______LAA Orifice Max Width ______mm

Thrombus: q Yes q No Reviewed by: ______Watchman Candidate q Yes q No

Indication: q History of major bleed q Fall Risk CTA q Windsock

q Patient Preference q Increased thromboembolic stroke risk q Chicken Wing

q Labile INR q Non-compliance with anticoagulation therapy q Cauliflower

Procedure Cancelled: q Yes q No

Reason: q Anatomy not conducive for implant q Appendage too large for device implant q Appendage too small for device implant q Catheterization challenge q Decompensation in patient condition q Epicardial access issue q Thrombus detected q Open heart device retrieval q Unanticipated patient condition q Patient/Family choice

Procedure Date: ______Anesthesia q Minimal q Moderate q Deep q General

Result ______mm Device ______Discharged on AC: q Warfarin q Aspirin q Other: ______

Procedure Aborted q Yes q No

Reason: q Anatomy not conducive for implant qAppendage too large for device implant q Appendage too small for device implant q Catheterization challenge q Decompensation in patient condition q Epicardial access issue q Thrombus detected q Open heart device retrieval q Unanticipated patient condition q Patient/Family choice

Follow up TEE: ______LAA seal < 5 mm q Yes q No ______

Anticoagulation stopped q Yes q No Plavix (clopidogrel) started q Yes q No q Aspirin 81 mg q Aspirin 325 mg

Follow up 1 year TEE: ______LAA seal < 5 mm q Yes q No

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Date Time Physician Signature PID#

*1-43196* FORM 1-43196 INITIATED 09/2017 Page 1 of 1