Book Loop-Recorder

The original PDF has no box for the First name: there is only the dotted line. Write first and last name together in the field Last name, or add the first name by hand on the printed form.

In the PDF, the Yes / No for allergies and pregnancy are not real checkboxes. The tick above counts as “yes”; if the answer is no, leave it empty.

“ECG and heart rate” is listed in the PDF but has no checkbox: attach it anyway.