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Printed Name of Health Care Professional and Degree Signature State License Number Telephone Fax Number Doctor s Comments DLD 134 Rev. 8-10 For overview see reverse side Stable for 6 months Class IV arrhythmia with loss of conscious uncontrolled Ht Class III unstable rhythm hypertension All Class I limits no symptoms on ordinary activity Class I rhythm stable with pacemaker for Symptoms with strenuous stable for 3 Diastolic under anticipated aggr.

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