<p>Children’s Hospital & Regional Medical Center Name: ______Electrophysiology Study Preliminary Report MRN: ______Study date: ______Page __ of __</p><p>Indication: ______Antiarrhythmia drugs: ______</p><p>Baseline intervals: SCL _____ PR _____ QRS _____ Mapping AH _____ HV _____ QT _____ QTc _____ Site Interval</p><p>Atrial Overdrive Pacing: Max SNRT ______CSNRT ______Site _____ AV Block Cycle Length _____ Atrial Extrastimulus Testing: Site BCL FPERP AVNERP APERP Decremental?  Y  N AMERP Pre-excited?  Y  N Ventricular Overdrive Pacing: Induced Arrhythmias: Site _____ VA Block Cycle Length _____ Site Ventricular Extrastimulus Testing: Sequence Site Morphology BCL TCL VAERP Termination VMERP Mechanism Decremental?  Y  N</p><p>Intervention: Drug/Procedure ______Atrial Extrastimulus Testing: Dose: ______Site BCL Baseline intervals: SCL _____ PR _____ QRS _____ FPERP AH _____ HV _____ QT _____ QTc _____ AVNERP APERP Atrial Overdrive Pacing: AMERP Max SNRT ______CSNRT ______Decremental?  Y  N Site _____ AV Block Cycle Length _____ Pre-excited?  Y  N</p><p>Ventricular Overdrive Pacing: Induced Arrhythmias: Site _____ VA Block Cycle Length _____ Site Ventricular Extrastimulus Testing: Sequence Site Morphology BCL TCL VAERP Termination VMERP Mechanism Decremental?  Y  N</p><p>Conclusions:</p><p>Electrophysiologist ______</p>