Form 7 Heart Candidate Registration

Records
Adult Heart Transplant Candidate Registration Worksheet
The revised worksheet sample is for reference purposes only and is pending OMB approval.
B.

Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI application.
Currently in the worksheet, a red asterisk is displayed by fields that are required, independent of what other data may be
B.

provided. Based on data provided through the online TIEDI application, additional fields that are dependent on responses
provided in these required fields may become required as well. However, since those fields are not required in every case,
they are not marked with a red asterisk.

Provider Information
Recipient Center:

Candidate Information
Date of Listing or
Add:

Organ Registered:

Last Name:

First Name:

MI:

Previous Surname:

SSN:

Gender:

HIC:

DOB:

State of Permanent Residence:
Permanent ZIP Code:
Is Patient waiting in permanent ZIP
code:

-

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

Ethnicity/Race:
(select all origins that apply)
American Indian or Alaska Native

c American Indian
d
e
f
g
c Eskimo
d
e
f
g
g Aleutian
c
d
e
f
c Alaska Indian
d
e
f
g
c American Indian or Alaska Native: Other
d
e
f
g
c American Indian or Alaska Native: Not
d
e
f
g

Specified/Unknown

Asian

c Asian Indian/Indian Subd
e
f
g
Continent
c Chinese
d
e
f
g
c Filipino
d
e
f
g
g Japanese
c
d
e
f
c Korean
d
e
f
g
c Vietnamese
d
e
f
g
c Asian: Other
d
e
f
g

j Female
k
l
m
j Male n
k
l
m
n

g Asian: Not Specified/Unknown
c
d
e
f
Black or African American

Hispanic/Latino

c African American
d
e
f
g

c Mexican
d
e
f
g

c African (Continental)
d
e
f
g

c Puerto Rican (Mainland)
d
e
f
g

c West Indian
d
e
f
g

c Puerto Rican (Island)
d
e
f
g

c Haitian
d
e
f
g

g Cuban
c
d
e
f

c Black or African American: Other
d
e
f
g

c Hispanic/Latino: Other
d
e
f
g

c Black or African American: Not
d
e
f
g
Specified/Unknown

c Hispanic/Latino: Not
d
e
f
g
Specified/Unknown

Native Hawaiian or Other Pacific Islander

White

c Native Hawaiian
d
e
f
g

c European Descent
d
e
f
g

c Guamanian or Chamorro
d
e
f
g

c Arab or Middle Eastern
d
e
f
g

c Samoan
d
e
f
g

g North African (non-Black)
c
d
e
f

c Native Hawaiian or Other Pacific Islander:
d
e
f
g
Other

c Native Hawaiian or Other Pacific Islander:
d
e
f
g

Not Specified/Unknown

c White: Other
d
e
f
g
c White: Not
d
e
f
g
Specified/Unknown

j U.S. CITIZEN
k
l
m
n
Citizenship:

j RESIDENT ALIEN
k
l
m
n
j NON-RESIDENT ALIEN, Year Entered US
k
l
m
n

Year of Entry to the U.S.

j NONE
k
l
m
n
j GRADE SCHOOL (0-8)
k
l
m
n
j HIGH SCHOOL (9-12)
k
l
m
n
Highest Education Level:

j ATTENDED COLLEGE/TECHNICAL SCHOOL
k
l
m
n
j ASSOCIATE/BACHELOR DEGREE
k
l
m
n
j POST-COLLEGE GRADUATE DEGREE
k
l
m
n
j N/A (< 5 YRS OLD)
k
l
m
n
j UNKNOWN
k
l
m
n

j IN INTENSIVE CARE UNIT
k
l
m
n

Medical Condition at time of listing:

j HOSPITALIZED NOT IN ICU
k
l
m
n
j NOT HOSPITALIZED
k
l
m
n

Patient on Life Support:

j YES n
k
l
m
n
j NO
k
l
m
c Extra Corporeal Membrane Oxygenation
d
e
f
g
c Intra Aortic Balloon Pump
d
e
f
g
c Prostaglandins
d
e
f
g
c Intravenous Inotropes
d
e
f
g
c Inhaled NO
d
e
f
g
c Ventilator
d
e
f
g
c Other Mechanism, Specify
d
e
f
g

Specify:

j NONE
k
l
m
n

j LVAD
k
l
m
n
Patient on Ventricular Assist Device:

j RVAD
k
l
m
n
j TAH
k
l
m
n
j LVAD+RVAD
k
l
m
n

VAD Brand1:
Specify:
VAD Brand2:
Specify:

Functional Status:

j No Limitations
k
l
m
n
Physical Capacity:

j Limited Mobility
k
l
m
n
j Wheelchair bound or more limited
k
l
m
n

j Not Applicable (< 1 year old or hospitalized)
k
l
m
n
j Unknown
k
l
m
n

Working for income:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

If No, Not Working Due To:

j Working Full Time
k
l
m
n
j Working Part Time due to Demands of Treatment
k
l
m
n
j Working Part Time due to Disability
k
l
m
n
j Working Part Time due to Insurance Conflict
k
l
m
n
If Yes:

j Working Part Time due to Inability to Find Full Time
k
l
m
n
Work
j Working Part Time due to Patient Choice
k
l
m
n
j Working Part Time Reason Unknown
k
l
m
n
j Working, Part Time vs. Full Time Unknown
k
l
m
n

j Within One Grade Level of Peers
k
l
m
n
j Delayed Grade Level
k
l
m
n
Academic Progress:

j Special Education
k
l
m
n
j Not Applicable < 5 years old
k
l
m
n
j Status Unknown
k
l
m
n

j Full academic load
k
l
m
n
j Reduced academic load
k
l
m
n
Academic Activity Level:

j Unable to participate in academics due to disease or
k
l
m
n
condition
j Not Applicable < 5 years old/ High School graduate
k
l
m
n
j Status Unknown
k
l
m
n

Previous Transplants:

Organ

Date

Graft Fail Date

The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than
three previous transplants by calling 800-978-4334 or by emailing [email protected].

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Previous Pancreas Islet Infusion:

Source of Payment:
Primary:
Specify:
Secondary:

Clinical Information: AT LISTING
Height:

ft.

Weight:

lbs

BMI:

in.

cm %ile ST=
kg

kg/m2

%ile ST=
%ile

ABO Blood Group:

Primary Diagnosis:
Specify:

General Medical Factors:

j No
k
l
m
n
j Type I
k
l
m
n
Diabetes:

j Type II
k
l
m
n
j Type Other
k
l
m
n
j Type Unknown
k
l
m
n
j Diabetes Status Unknown
k
l
m
n

j No dialysis
k
l
m
n

j Hemodialysis
k
l
m
n

j Peritoneal Dialysis
k
l
m
n
Dialysis:

j Dialysis Status Unknown
k
l
m
n
j Dialysis-Unknown Type was performed
k
l
m
n

j No
k
l
m
n
Peptic Ulcer:

j Yes, active within the last year
k
l
m
n
j Yes, not active within the last year
k
l
m
n
j Unknown
k
l
m
n

j No angina
k
l
m
n
j Stable angina - strenuous activity results in angina
k
l
m
n
j Stable angina - ordinary physical activity results in
k
l
m
n
angina
Angina:

j Stable angina - no rest angina; does have angina with
k
l
m
n
less than ordinary activity

j Stable angina - angina with any physical activity or at
k
l
m
n

rest

j Unstable angina
k
l
m
n
j Unknown if angina present
k
l
m
n

Drug Treated Systemic Hypertension:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

Symptomatic Cerebrovascular
Disease:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

Symptomatic Peripheral Vascular
Disease:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

Drug Treated COPD:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

Pulmonary Embolism:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Any Previous Transfusions:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Any previous Malignancy:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

c Skin Melanoma
d
e
f
g
c Skin Non-Melanoma
d
e
f
g
c CNS Tumor
d
e
f
g
c Genitourinary
d
e
f
g
c Breast
d
e
f
g
Specify Type:

c Thyroid
d
e
f
g
c Tongue/Throat/Larynx
d
e
f
g
c Lung
d
e
f
g
c Leukemia/Lymphoma
d
e
f
g
c Liver
d
e
f
g

c Other, specify
d
e
f
g
Specify:
Most Recent Serum Creatinine:

ST=
mg/dl

Total Serum Albumin:

g/dl

ST=

Heart Medical Factors:
Sudden Death:

j YES n
k
l
m
n
j NO n
k
l
m
j
k
l
m
UNK

Antiarrhythmics:

j
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
UNK

Amiodarone:

j YES n
k
l
m
n
j NO n
k
l
m
j
k
l
m
UNK

Implantable Defibrillator:

j
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
UNK

Infection Requiring IV Drug Therapy
within 2/wks prior to listing:

j YES n
k
l
m
n
j NO n
k
l
m
j
k
l
m
UNK

Exercise Oxygen Consumption:

ST=
ml/min/kg

Most Recent Hemodynamics:

Inotropes/Vasodilators:
ST=

j YES n
k
l
m
n
j NO
k
l
m

PA (sys) mm/Hg:
ST=

j YES n
k
l
m
n
j NO
k
l
m

PA (dia) mm/Hg:
ST=

j YES n
k
l
m
n
j NO
k
l
m

PA (mean) mm/Hg:
ST=

j NO
k
l
m
j YES n
k
l
m
n

PCW (mean) mm/Hg:
ST=

j NO
k
l
m
j YES n
k
l
m
n

CO L/min:

History of Cigarette Use:

j YES n
k
l
m
n
j NO
k
l
m
j 0-10
k
l
m
n
j 11-20
k
l
m
n
j 21-30
k
l
m
n

If Yes, Check # pack years:

j 31-40
k
l
m
n
j 41-50
k
l
m
n
j >50
k
l
m
n
j Unknown pack years
k
l
m
n
j 0-2 months
k
l
m
n

j 3-12 months
k
l
m
n
j 13-24 months
k
l
m
n
Duration of Abstinence:

j 25-36 months
k
l
m
n
j 37-48 months
k
l
m
n
j 49-60 months
k
l
m
n
j >60 months
k
l
m
n

j Continues To Smoke
k
l
m
n
j Unknown duration
k
l
m
n
Other Tobacco Use:

Prior Cardiac Surgery (non-transplant):

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

c CABG
d
e
f
g
c Valve Replacement/Repair
d
e
f
g
If yes, check all that apply:

c Congenital
d
e
f
g
c Left Ventricular Remodeling
d
e
f
g
c Other, specify
d
e
f
g

Specify:
Prior Lung Surgery (non-transplant):

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m

c Pneumoreduction
d
e
f
g
c Pneumothorax Surgery-Nodule
d
e
f
g
c Pneumothorax Decortication
d
e
f
g
If yes, check all that apply:

c Lobectomy
d
e
f
g
c Pneumonectomy
d
e
f
g
c Left Thoracotomy
d
e
f
g
c Right Thoracotomy
d
e
f
g
c Other, specify
d
e
f
g

Specify: