Carnation
RECORD SYMPTOMS
Follow your physician’s instructions carefully
The patient diary is an important part of this procedure.
Use this diary to document any symptoms you
experience
If a high pitched tone continuously repeats, patient should
remove the device and notify their physician.
Symptoms include:
Security Screening Statement
This person is wearing a Carnation
Ambulatory Monitor (records ECG). It was
applied under direction from their
physician. The device is currently adhered
to the patient’s chest and is monitoring
their heart.
Symptoms include:
1) Chest discomfort/pain
2) Dizziness
3) Lightheadedness
Date/Time: MM
/
Questions? Contact your Physician.
Traveling through airports: Inform screening
personnel that you are wearing the Carnation
Ambulatory Monitor before going through scanner.
Bring this Patient Diary to show security personnel.
DD
/
4) Shortness of breath
5) Palpitations
6) Passing out or nearly
YY
Symptom:
Date/Time: MM
/
DD
/
Symptom:
Date/Time: MM
/
DD
/
/
DD
/
MPS Medical Product Service GmbH
Borngasse 20
35619 Braunfels
Germany
0459
Carnation Ambulatory Monitor Patient Diary DWG000135C 06-2016
Date/Time: MM
/
DD
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Date/Time: MM
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DD
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HH
Date/Time: MM
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DD
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YY
:
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AM
PM
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AM
PM
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#
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PM
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PM
PHYSICIAN NAME:
P
:
P
Phon :
DEVICE APPLIED (very important!):
Date/Time: MM
/
DD
/
YY
HH
:
MM
AM
PM
MM
/
DD
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MM
AM
PM
Place barcode label here
HH
:
MM
AM PM
Select all that apply
1. Syncope of uncertain etiology
2. Pre-syncope of uncertain etiology
4. Management of known atrial fibrillation (AF)
HH
:
MM
AM
PM
#
HH
:
MM
HH
:
MM
AM
PM
#
AM
PM
#
YY
Symptom:
AM
Hosp. ID:
PATIENT HOSPITAL ID#
3. Palpitations of uncertain etiology
YY
Symptom:
HH
#
DD
HH
MM
Clinical Staff: Fill out this tab,
tear off, and place inside Mailer
Reason for Monitor
YY
Symptom:
HH
:
Patient Diary
#
YY
Symptom:
HH
#
YY
Symptom:
YY
Symptom:
PM
#
YY
Symptom:
AM
4) Shortness of breath
5) Palpitations
6) Passing out or nearly
Symptom:
YY
Symptom:
:
MM
1) Chest discomfort/pain
2) Dizziness
3) Lightheadedness
#
YY
Symptom:
Date/Time: MM
HH
YY
Bardy Diagnostics Inc.
Charlotte, NC 28207
USA
US Customer Service: (844) 422-7393
EU Customer service: +31 (0)46 7630422
Ambulatory Monitor
1. Following your normal daily activities, wear the
Carnation Ambulatory Monitor for 7 Days,
including while you shower.
NOTE: Based on your activity level and the
amount you sweat, your time of wear may
be less than 7 days.
2. If you feel symptoms that may be related to your
heart, push the button and record date/time in this
diary.
5. Management of known supraventricular
tachycardia (SVT)
6. Management of known ventricular
tachycardia (VT)
7. Other reason:
Implantable Cardioverter
Defibrillator (ICD)?
YES
NO
Pacemaker
Alone or part of ICD therapy
YES
NO
Ventricular Only?
Dual Chamber?
HH
#
Wearing the Carnation Ambulatory Monitor:
:
MM
AM
PM
PUSH
when you feel
SYMPTOMS
Cardiac Resynchronization Therapy (CRT)?
Atrial Only?
Other related device information pertinent to this
ECG monitoring exercise:
INSTRUCTIONS FOR WEARING THE CARNATION AMBULATORY MONITOR
3. Wear the Carnation Ambulatory Monitor at all
times, including showering.
CAUTION: Submersion (such as during swimming or
bathing) will shorten wear time. Keep showers brief, and
the Carnation Ambulatory Monitor out of the direct stream
of water.
5. Returning the Carnation Ambulatory Monitor:
Place the Carnation Ambulatory Monitor and this
patient diary in the mailer.
6. Seal the mailer with the Mailer Sticker and return
/
DD
/
4) Shortness of breath
5) Palpitations
6) Passing out or nearly
YY
Symptom:
Ambu
+
Patient
Date/Time: MM
Diary
N:
PHYSICIA
START
WEAR
E:
DATE/TIM
UNTIL
PHYSICIA
E:
DATE/TIM
N PHONE:
PHONE:
ns
’s instructio
your PhysicianPhysician
PATIENT
Follow
Questions?
Contact
your
place barcode
/
Mailer Sticker
PATIENT
DD
/
Symptom:
label here
:
MM
AM
PM
/
DD
/
Date/Time: MM
/
DD
/
:
MM
AM
PM
Date/Time: MM
/
#
DD
/
:
MM
HH
:
MM
HH
:
MM
HH
:
MM
HH
:
MM
HH
:
MM
HH
:
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PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
#
YY
Symptom:
AM
#
YY
Symptom:
HH
HH
YY
Symptom:
#
YY
#
ostics Inc
Date/Time: MM
/
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/
YY
Symptom:
Date/Time: MM
/
DD
/
Date/Time: MM
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DD
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/
DD
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MM
AM
PM
Date/Time: MM
/
DD
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YY
Symptom:
HH
:
MM
AM
PM
Date/Time: MM
/
#
DD
/
HH
:
MM
AM
PM
Date/Time: MM
/
#
/
:
MM
AM
PM
Date/Time: MM
/
DD
/
#
YY
Symptom:
HH
#
DD
#
YY
Symptom:
YY
Symptom:
:
#
YY
Symptom:
Date/Time: MM
HH
YY
Symptom:
Pad to Remove Adhesive
HH
Date/Time: MM
Bardy Diagn
Mailer Sticker (Step 6)
Pad to Remove
Adhesive and peel
Monitor off skin
(Step 4)
1) Chest discomfort/pain
2) Dizziness
3) Lightheadedness
Date/Time: MM
ation
or
Carn
:
latory Monit
More space for recording symptoms
Symptoms include:
per your doctor/nurse instructions.
CAUTION: Skin irritation. Minor itching or irritation is
normal. Only remove before 7 days if irritation from the
adhesive is not tolerable. Mark time/date of removal.
CAUTION: Loose electrodes can degrade
performance. Press the Carnation Ambulatory Monitor
back in place if it becomes loose or detached.
4. Removing the Carnation Ambulatory Monitor:
When the test is complete, remove by pressing fingers
against the skin and slowly peeling off the Carnation
Ambulatory Monitor while wiping between the skin and the
device with the Pad to remove adhesive.
RECORD SYMPTOMS
#
YY
Symptom:
#