Heart Candidate Registration Instructions

Heart Transplant Candidate Registration (TCR)
Record Field Descriptions
The Transplant Candidate Registration (TCR) record is generated at the time that a candidate
for transplant is added to the OPTN/UNOS waiting list. A TCR will also be generated in the
case of a living donor transplant, where the recipient was not added to the Waitlist, and was
added through the living donor feedback process.
If the candidate is already on the waiting list for a transplant, another TCR record will not be
generated unless listed by a different center or for another organ type.
View OPTN/UNOS Policy on Data Submission Requirements for additional information.
To correct information that is already displayed on an electronic record, call 1-800-978-4334.
Provider Information
Recipient Center: The recipient center will display. Verify the transplant center name and the
center code, and the provider number, (6-character Medicare identification number of the
hospital where the transplant recipient was transplanted) are correct.
Candidate Information
Organ Registered: Verify the organ(s) displayed is/are the organ(s) listed for this candidate. If
the candidate is listed for more than one type of transplant, both organs should be displayed.
Separate records exist for certain multi-organ transplant candidates (e.g. Heart/Lung and
Kidney/Pancreas).
Date of Listing or Add: The date the candidate was listed or added in Waitlist will display.
Name: The waitlisted candidate's last name, first name and middle initial will be displayed. If it
is incorrect, corrections must be completed on the active waitlist. For a candidate who has been
removed from the waitlist, the Last Name, First Name and MI fields will display. Corrections
may be made directly in the record.
Previous Surname: If the candidate had a previous surname that is different from the Name
entered, enter the previous surname.
SSN: Verify the candidate's social security number. If the information is incorrect and the
candidate is waitlisted, contact the UNOS Organ Center at 1-800-292-9537.
Gender: Verify candidate's gender. If the gender is not displayed or is incorrect and the
candidate is on the active waitlist, correction must be completed on the active waitlist record. If
the candidate has been removed from the active waitlist, corrections may be made directly in
the record.
HIC: Enter the 9 to 11 character Health Insurance Claim number for the candidate. If the
candidate does not have a HIC number, you may leave this field blank.
DOB: Verify the displayed date is the candidate's date of birth. If the information is incorrect,
correction must be completed on the active waitlist. If the candidate has been removed, reenter
the correct date using the 8-digit numeric format of MM/DD/YYYY. Corrections may be made
directly in the record.
State of Permanent Residence: Select the name of the state of the candidate's permanent
address.
Permanent Zip Code: Enter the candidate's permanent zip code.
Is Patient waiting in permanent ZIP code: If the candidate is waiting in the permanent zip
code, select Yes. If not, select No. If unknown, select UNK. This field is optional.

Ethnicity/Race: Select all origins that indicate the candidate's ethnicity/race.
American Indian or Alaska Native: Select for candidates who are of North, South, or
Central American descent (e.g. American Indian, Eskimo, Aleutian, Alaska Indian). If
the candidate belongs to the primary category, but does not belong to any of the
subcategories listed, select American Indian or Alaska Native: Other. If unknown, select
American Indian or Alaska Native: Not Specified/Unknown.
Asian: Select for candidates who are of Asian descent (e.g. Asian Indian/Indian SubContinent, Chinese, Filipino, Japanese, Korean, Vietnamese). If the candidate belongs
to the primary category, but does not belong to any of the subcategories listed, select
Asian: Other. If unknown, select Asian: Not Specified/Unknown.
Black or African American: Select for candidates of African descent (e.g. African
American, African (Continental), West Indian, Haitian). If the candidate belongs to the
primary category, but does not belong to any of the subcategories listed, select Black or
African American: Other. If unknown, select Black or African American: Not
Specified/Unknown.
Hispanic/Latino: Select for candidates who are of Central or South American descent (e.g.
Mexican, Puerto Rican (Mainland), Puerto Rican (Island), Cuban). If the candidate
belongs to the primary category, but does not belong to any of the subcategories listed,
select Hispanic/Latino: Other. If unknown, select Hispanic/Latino: Not
Specified/Unknown.
Native Hawaiian or Other Pacific Islander: Select for candidates who are descendents of
the Native Hawaiian, Guamanian or Chamorro, or Samoan peoples. If the candidate
belongs to the primary category, but does not belong to any of the subcategories listed,
select Native Hawaiian or Other Pacific Islander: Other. If unknown, select Native
Hawaiian or Other Pacific Islander: Not Specified/Unknown.
White: Select for candidates who are of European Descent, Arab or Middle Eastern or
North African (non-Black). If the candidate belongs to the primary category, but does not
belong to any of the subcategories listed, select White: Other. If unknown, select White:
Not Specified/Unknown.
Citizenship: Select as appropriate to indicate the candidate's citizenship.
U.S. Citizen: Select if the candidate is a U.S. Citizen by birth or naturalization.
Resident Alien: Select if the candidate is a non-U.S. citizen currently residing in the United
States (e.g., Permanent Resident, Conditional Resident, Returning Resident). A Permanent
Resident is an individual residing in the U.S. under legally recognized and lawfully recorded
residence as an immigrant. A Conditional Resident is any alien granted permanent resident
status on a conditional basis (e.g., a spouse of a U.S. Citizen; an immigrant investor), who
is required to petition for the removal of the set conditions before the second anniversary of
the approval of the conditional status. A Returning Resident is any lawful permanent
resident who has been outside the United States and is returning to the U.S. (Also defined
as a "special immigrant".)
Non-Resident Alien/Year entered U.S.: If the candidate is a Non-Resident Alien
(Nonimmigrant), enter the year the candidate entered the United States. A Nonimmigrant is
an alien who seeks temporary entry to the United States for a specific purpose. The alien
must have a permanent residence abroad and qualify for the nonimmigrant classification
sought. The nonimmigrant classifications include: foreign government officials, visitors for
business and for pleasure, aliens in transit through the U.S., treaty traders and investors,
students, international representatives, temporary workers and trainees, representatives of
foreign information media, exchange visitors, fiance(e)s of U.S. citizens, intracompany
transferees, NATO officials, religious workers, and some others. Most non-immigrants can
be accompanied or joined by spouses and unmarried minor (or dependent) children.

Note: Permanent residence begins on the date the candidate was granted permanent
resident status. This date is on the candidate's Permanent Resident Card
(formerly known as Alien Registration Card). To view a sample card, go to
http://www.immigrationagency.org/images/greencard_sample.jpg.
Highest Education Level: Select the choice which best describes the living donor's highest
level of education.
None
Grade School (0-8)
High School (9-12)
Attended College/Technical School
Associate/Bachelor Degree
Post-College Graduate Degree
N/A (< 5 Yrs Old)
Unknown
Medical Condition at time of listing: Select the choice that best describes the candidate's
medical condition at the time of listing. This field is optional.
In Intensive Care Unit
Hospitalized Not in ICU
Not Hospitalized
Patient on Life Support: If the candidate was on life support at the time of listing, select Yes. If
not, select No. If Yes, select life support types that apply. If Other Mechanism, Specify is
selected, enter the type of mechanism in the space provided.
Extra Corporeal Membrane Oxygenation
Intra Aortic Balloon Pump
Prostaglandins
Intravenous Inotropes
Inhaled NO
Ventilator - Select only if the candidate was on continuous invasive ventilation.
Other Mechanism, Specify
Patient on Ventricular Assist Device: If the candidate was on a Ventricular Assist Device
(VAD), select the type. If the candidate was not on a VAD, select None.
If a VAD was indicated, select the brand of device that the candidate was on. If
LVAD+RVAD was indicated, select the brand of device the candidate was on for both
LVAD and RVAD. If Other, Specify is selected for one of the following, specify the name in
the space provided.
LVAD:
Abiomed BVS
Arrow Lionheart
Berlin Heart
Biomedicus
Heartmate II
Heartmate IP
Heartmate VE
Heartmate XVE
Heartsaver VAD
Jarvik 2000
Medos
Micromed DeBakey
Novacor PC
Novacor PCq
Pittsburgh AB180

Thoratec
Thoratec IVAD
Toyobo
Other, Specify
RVAD:
Abiomed BVS
Berlin Heart
Biomedicus
Medos
Thoratec
Thoratec IVAD
Toyobo
Other, Specify
TAH:
AbioCor
Cardiowest
Other, Specify
LVAD + RVAD:
Functional Status: Select the choice that best describes the candidate's functional status.
Note: The Karnofsky Index will display for adults aged 18 and older.
10% - Moribund, fatal processes progressing rapidly
20% - Very sick, hospitalization necessary: active treatment necessary
30% - Severely disabled: hospitalization is indicated, death not imminent
40% - Disabled: requires special care and assistance
50% - Requires considerable assistance and frequent medical care
60% - Requires occasional assistance but is able to care for needs
70% - Cares for self: unable to carry on normal activity or active work
80% - Normal activity with effort: some symptoms of disease
90% - Able to carry on normal activity: minor symptoms of disease
100% - Normal, no complaints, no evidence of disease
Unknown
Note: The Lansky Scale will display for pediatrics aged 1 to 17.
10% - No play; does not get out of bed
20% - Often sleeping; play entirely limited to very passive activities
30% - In bed; needs assistance even for quiet play
40% - Mostly in bed; participates in quiet activities
50% - Can dress but lies around much of day; no active play; can take part in quiet
play/activities
60% - Up and around, but minimal active play; keeps busy with quieter activities
70% - Both greater restriction of and less time spent in play activity
80% - Active, but tires more quickly
90% - Minor restrictions in physically strenuous activity
100% - Fully active, normal
Not Applicable (patient < 1 year old)
Unknown
Note: This evaluation should be in comparison to the person's normal function, indicating
how the patient's disease has affected their normal function.
Physical Capacity: (Complete for candidates older than 18 years of age.)Select the choice
that best describes the candidate's physical capacity at the time of listing. If the candidate's

Medical Condition indicates they are hospitalized, select Not Applicable (hospitalized). This
field is optional for adult candidates.
No Limitations
Limited Mobility
Wheelchair bound or more limited
Not Applicable (hospitalized)
Unknown
Physical Capacity is the ability to perform bodily activities such as walking, dressing,
bathing, grooming, etc.
Cognitive Development: (Complete for candidates 18 years of age or younger.) Select the
choice that best describes the candidate's cognitive development at the time of listing.
Definite Cognitive Delay/Impairment (verified by IQ score <70 or unambiguous
behavioral observation)
Probable Cognitive Delay/Impairment (not verified or unambiguous but more likely than
not, based on behavioral observation or other evidence)
Questionable Cognitive Delay/Impairment (not judged to be more likely than not, but
with some indication of cognitive delay/impairment such as expressive/receptive language
and/or learning difficulties)
No Cognitive Delay/Impairment (no obvious indicators of cognitive delay/impairment)
Not Assessed
Motor Development: (Complete for candidates 18 years of age or younger.) Select the choice
that best describes the candidate's motor development at the time of listing.
Definite Motor Delay/Impairment (verified by physical exam or unambiguous behavioral
observation)
Probable Motor Delay/Impairment (not verified or unambiguous but more likely than not,
based on behavioral observation or other evidence)
Questionable Motor Delay/Impairment (not judged to be more likely than not, but with
some indication of motor delay/impairment)
No Motor Delay/Impairment (no obvious indicators of motor delay/impairment)
Not Assessed
Working for income? (Complete for candidates 19 years of age or older.) If the candidate is
working for income, select Yes. If not, select No. If unknown, select UNK.
If Yes: If Yes is selected, indicate the candidate's working status. This field is optional for
adult candidates only.
Working Full Time
Working Part Time due to Demands of Treatment
Working Part Time due to Disability
Working Part Time due to Insurance Conflict
Working Part Time due to Inability to Find Full Time Work
Working Part Time due to Patient Choice
Working Part Time Reason Unknown
Working, Part Time vs. Full Time Unknown
If No, Not Working Due To: If No is selected, indicate the reason why the candidate is not
working at the time of listing. This field is optional for adult candidates only.
Disability - A physical or mental impairment that interferes with or prevents a
candidate from working (e.g. arthritis, mental retardation, cerebral palsy, etc).

Demands of Treatment - An urgent medical treatment that prevents a candidate from
working (e.g. Dialysis).
Insurance Conflict - Any differences between a candidate and insurance company
that prevents them from working.
Inability to Find Work - The lack of one's ability to find work. (e.g. lack of
transportation, work experience, over qualification, unavailable work, etc.)
Patient Choice - Homemaker - A candidate who chooses to manage their own
household, instead of performing work for pay.
Patient Choice - Student Full Time/Part Time - A candidate who is enrolled and/or
participating in college.
Patient Choice - Retired - A candidate who no longer has an active working life such
as an occupation, business or office job.
Patient Choice - Other - Any reason not listed above that would prevent a candidate
from working.
Not Applicable - Hospitalized - Select only if the patient's Medical Condition indicates
they are in the hospital.
Unknown
Academic Progress: (Complete for candidates 18 years of age or younger.) Select the choice
that best describes the candidate's academic progress at the time of listing.
Within One Grade Level of Peers
Delayed Grade Level
Special Education
Not Applicable <5 years old
Status Unknown
Academic Activity Level: (Complete for candidates 18 years of age or younger.) Select the
choice that best describes the candidate's academic activity level at the time of listing. If the
candidate is less than 5 years old or has graduated from high school, select Not Applicable <
5 years old/High School graduate.
Full academic load
Reduced academic load
Unable to participate in academics due to disease or condition
Not Applicable <5 years old/High School graduate
Previous Transplants: The three most recent transplant(s), indicated on the candidate's
validated Transplant Recipient Registration (TRR) record(s), will display. Verify all previous
transplants listed by organ type, transplant date and graft failure date.
Note: The three most recent transplants on record for this candidate will be displayed for
verification. If there are any prior transplants that are not listed here, contact the UNet
Helpdesk at 1-800-978-4334 or [email protected] to determine if the
transplant event is in the database.
Previous Pancreas Islet Infusion: If the candidate received a previous pancreas islet infusion,
select Yes. If not, select No. If unknown, select UNK. This field is optional for pediatric
candidates only.
Source of Payment:
Primary: Select as appropriate to indicate the candidate's source of primary payment
(largest contributor) for the transplant. If the source of payment is not yet determined, select
Pending.

Private insurance refers to funds from agencies such as Blue Cross/Blue Shield, etc.
It also refers to any worker's compensation that is covered by a private insurer.
Public insurance - Medicaid refers to state Medicaid funds.
Public insurance - Medicare FFS (Fee-for-Service) refers to funds from the
government in which doctors and other health care providers are paid for each service
provided to a candidate. For additional information about Medicare, see
http://www.medicare.gov/Choices/Overview.asp.
Public insurance - Medicare & Choice (also known as Medicare Managed Care)
refers to funds from the government in which doctors and other health care providers
are paid for each service provided to a candidate, along with additional benefits (i.e.
coordination of care or reducing-out-of-pocket expenses. Sometimes a candidate may
receive additional benefits such as prescription drugs.). For additional information
about Medicare, see http://www.medicare.gov/Choices/Overview.asp.
Public insurance - CHIP (Children's Health Insurance Program)
Public insurance - Department of VA refers to funds from the Veterans
Administration.
Public insurance - Other government refers to funds from another government
agency.
Self indicates that the candidate will pay for the cost of transplant.
Donation indicates that a company, institution, or individual(s) donated funds to pay for
the transplant and care of the candidate.
Free Care indicates that the transplant hospital will not charge candidate for the costs
of the transplant operation.
Pending is used if the source of payment is not yet determined (Primary only)
Foreign Government, Specify refers to funds provided by a foreign government
(Primary only) Specify the foreign country in the space provided.
Secondary: Select as appropriate to indicate the candidate's source of secondary
payment. This field is optional.
Private insurance refers to funds from agencies such as Blue Cross/Blue Shield, etc.
It also refers to any worker's compensation that is covered by a private insurer.
Public insurance - Medicaid refers to state Medicaid funds.
Public insurance - Medicare FFS (Fee-for-Service) refers to funds from the
government in which doctors and other health care providers that are paid for each
service provided to a candidate. For additional information about Medicare, see
http://www.medicare.gov/Choices/Overview.asp.
Public insurance - Medicare & Choice (also known as Medicare Managed Care)
refers to funds from the government in which doctors and other health care providers
are paid for each service provided to a candidate, along with additional benefits (i.e.
coordination of care or reducing-out-of-pocket expenses. Sometimes a candidate may
receive additional benefits such as prescription drugs.). For additional information
about Medicare, see http://www.medicare.gov/Choices/Overview.asp.
Public insurance - CHIP (Children's Health Insurance Program)
Public insurance - Other government refers to funds from another government
agency.
Self indicates that the candidate will pay for the cost of transplant.

Donation indicates that a company, institution, or individual(s) donated funds to pay for
the transplant and care of the candidate.
Free Care indicates that the transplant hospital will not charge candidate for the costs
of the transplant operation.
None - Select if the candidate does not have a secondary source of payment.
Clinical Information: At Listing
Date of Measurement: (Complete for candidates 18 years of age or younger.) Enter the date,
using the 8-digit format of MM/DD/YYYY, the candidate’s height and weight were measured.
Height: Enter the height of the candidate at the time of listing in the appropriate space, in feet
and inches or centimeters. If the candidate’s height is unavailable, select the appropriate status
from the ST field (N/A, Not Done, Missing, Unknown). For candidates 18 years old or younger
at the time of listing, UNet will generate and display calculated percentiles based on the 2000
CDC growth charts.
Weight: Enter the weight of the candidate at the time of listing in the appropriate space, in
pounds or kilograms. If the candidate’s weight is unavailable, select the appropriate status from
the ST field (N/A, Not Done, Missing, Unknown). For candidates 18 years old or younger at
the time of listing, UNet will generate and display calculated percentiles based on the 2000
CDC growth charts.
BMI (Body Mass Index): The candidate's BMI will display. For candidates 18 years old or
younger, at the time of listing, UNetSM will generate and display calculated percentiles based on
the 2000 CDC growth charts.
Percentiles are the most commonly used clinical indicator to assess the size and growth
patterns of individual children in the United States. Percentiles rank the position of an
individual by indicating what percent of the reference population the individual would equal
or exceed (i.e. on the weight-for-age growth charts, a 5 year-old girl whose weight is at the
25th percentile, weighs the same or more than 25 percent of the reference population of 5year-old girls, and weighs less than 75 percent of the 5-year-old girls in the reference
population). For additional information about CDC growth charts, see http://www.cdc.gov/.
ABO Blood Group: The candidate's blood type will be displayed. If the blood type is incorrect,
correction must be completed on the active waitlist. If the candidate has been removed from the
active waitlist, you may select the candidate's correct blood type directly in the record.
A
A1
A1B
A2
A2B
AB
B
O
Z (In Utero Only)
Primary Diagnosis: Select the primary diagnosis for the disease requiring a transplant at
the time of listing for this candidate. If the candidate has had a previous transplant for the same
organ type, use Retransplant/Graft Failure as the primary diagnosis for that organ. If an Other
code is selected, use the blank provided to specify the Other diagnosis.
General Medical Factors: For each of the medical factors listed, select the appropriate
responses to indicate if the candidate has a history of the factor prior to listing.
Diabetes: If the candidate does not have a history of diabetes, select No. If the candidate
has diabetes, select Type I or Type II. If the candidate has any type of induced diabetes,

select Type Other. If the candidate has a history of diabetes but the type is unknown,
select Type Unknown. If this information is unknown, select Diabetes Status Unknown.
No
Type I is defined as a disease in which the body does not produce any insulin, most
often occurring in children and young adults. People with Type 1 diabetes must take
daily insulin injections to stay alive. Type 1 diabetes accounts for 5 to 10 percent of
diabetes.
Type II is defined as a metabolic disorder resulting from the body's inability to make
enough, or properly use, insulin. It is the most common form of the disease. Type 2
Diabetes accounts for 90 to 95 percent of diabetes.
Type Other
Type Unknown
Diabetes Status Unknown
Dialysis: If the candidate does not have a history of dialysis, select No. If the candidate
has a history of dialysis, select the type of dialysis. If the candidate has a history of dialysis,
but the type is not known, select Dialysis - Unknown Type was performed. If this
information is not known, select Dialysis Status Unknown. This field is optional for adult
candidates.
No Dialysis
Hemodialysis
Peritoneal Dialysis
Dialysis - Unknown Type was performed
Dialysis Status Unknown
Peptic Ulcer: If the candidate does not have a history of peptic ulcer, select No. If the
candidate has a history, select Yes. If this information is not known, select Unknown. This
field is optional.
No
Yes, active within the last year
Yes, not active within the last year
Unknown
Angina: If the candidate does not have a history of angina, select No angina. If the
candidate has a history of angina at the time of listing, select the appropriate Stable or
Unstable choice. If this information is not known, select Unknown if angina present. This
field is optional.
No angina
Stable angina - strenuous activity results in angina
Stable angina - ordinary physical activity results in angina
Stable angina - no rest angina; does have angina with less than ordinary activity
Stable angina - angina with any physical activity or at rest
Unstable angina
Angina, stability unknown
Unknown if angina present
Angina Severe constricting pain in the chest area.
Stable Angina - People with stable angina (or chronic stable angina) have
episodes of chest discomfort that are usually predictable. They occur on exertion
(such as running to catch a bus) or under mental or emotional stress. Normally
the chest discomfort is relieved with rest, nitroglycerin or both.
Unstable Angina - In people with unstable angina, the chest pain is unexpected
and usually occurs while at rest. The discomfort may be more severe and
prolonged than typical angina or be the first time a person has angina.

Drug Treated Systemic Hypertension: If the candidate is being treated or has a history of
being treated with any medication for the purpose of lowering blood pressure at the time of
listing, select Yes. If not, select No. If unknown, select UNK. This field is optional.
Symptomatic Cerebrovascular Disease: If the candidate is experiencing or has a history
of signs and symptoms of transient ischemic attacks or stroke at the time of listing, select
Yes. If not, select No. If unknown, select UNK.
Symptomatic Peripheral Vascular Disease: If the candidate is experiencing or has a
history of intermittent claudication, diminished peripheral pulses or other signs and
symptoms of peripheral vascular disease at the time of listing, select Yes. If not, select No.
If unknown, select UNK. This field is optional.
Drug Treated COPD: If the candidate is currently or has a history of taking any medication
to control signs and symptoms of COPD (Chronic Obstructive Pulmonary Disease) at the
time of listing, select Yes. If not, select No. If unknown, select UNK. This field is optional.
Pulmonary Embolism: If the candidate has been diagnosed as having a pulmonary
embolism within the past six months, select Yes. If not, select No. If unknown, select UNK.
This field is optional.
Any previous transfusions: If the candidate had any previous transfusions, select Yes. If
not, select No. If unknown, select UNK. This field is optional.
Any previous malignancy: If the candidate has history of any previous malignant cancer
prior to the time of listing, select Yes. If the candidate has not had a history of any previous
malignant cancer prior to the time of listing, select No. If unknown, select UNK. If Yes is
selected, select the type(s) of malignancy. If Other, Specify is selected, indicate the type of
tumor in the space provided.
Skin Melanoma
Skin Non-Melanoma
CNS Tumor
Genitourinary
Breast
Thyroid
Tongue/Throat/Larynx
Lung
Leukemia/Lymphoma
Liver
Other, specify
Most Recent Serum Creatinine: Enter the most recent serum creatinine value in mg/dl. If
the value is unavailable, select the appropriate status from the ST field (N/A, Not Done,
Missing, Unknown).
Total Serum Albumin: Enter the total serum albumin value in g/dl. If the value is
unavailable, select the appropriate status from the ST field (N/A, Not Done, Missing,
Unknown). This field is optional for adult candidates.
Heart Medical Factors
Sudden Death: If the candidate has experienced any episodes of sudden death (cardiac arrest
with resuscitation) prior to the time of listing, select Yes. If not, select No. If unknown, select
UNK. This field is optional for adult candidates.
Antiarrythmics: If the candidate is taking or has a history of taking any medication other than
Amiodarone for the purpose of controlling any diagnosed arrhythmia at the time of listing, select
Yes. If not, select No. If unknown, select UNK. This field is optional.
Amiodarone: If the candidate was taking or has a history of taking Amiodarone at the time of
listing, select Yes. If not, select No. If unknown, select UNK. This field is optional.

Implantable Defibrillator: If the candidate had an implantable defibrillator at the time of listing,
select Yes. If not, select No. If unknown, select UNK.
Infection Requiring IV Drug Therapy within 2/wks prior to listing: If the candidate had an
infection that required an IV Drug Therapy within 2 weeks prior to listing, select Yes. If not,
select No. If unknown, select UNK. This field is optional.
Exercise Oxygen Consumption: Enter the candidate's oxygen consumption at exercise in
ml/min/kg. If the value is unavailable, select the appropriate status from the ST field (N/A, Not
Done, Missing, Unknown).
Most recent Hemodynamics: Enter the most recent hemodynamic values. For each measure,
indicate if the measurement was obtained while the candidate was on Inotropes or
Vasodilators. If the tests were not done, select Not Done in the ST field (N/A, Not Done,
Missing, Unknown).
PA (sys) mm/Hg - systolic pulmonary artery pressure
PA (dia) mm/Hg - diastolic pulmonary artery pressure
PA (mean) mm/Hg - mean pulmonary artery pressure
PCW (mean) mm/Hg - mean pulmonary capillary wedge pressure
CO L/min - cardiac output
History of Cigarette Use: If the candidate has a history of cigarette use, select Yes. If not,
select No. If Yes is selected, indicate the number of pack years. Then indicate the Duration of
Abstinence.
If Yes, Check # of pack years is the number of packs of cigarettes the candidate smoked
per day multiplied by the number of years. For example a candidate smoking 2 packs of
cigarettes per day for 10 years would equal 20 pack years. This field is optional.
0-10
11-20
21-30
31-40
41-50
>50
Unknown pack years
Duration of Abstinence: Select the number of months the candidate has abstained from
cigarettes. If the time is unknown, select Unknown duration. If the candidate has not
stopped smoking, select Continues To Smoke.
0-2 months
3-12 months
13-24 months
25-36 months
37-48 months
49-60 months
>60 months
Continues To Smoke
Unknown duration
Other Tobacco Use: If the candidate has a history of other tobacco use, select Yes. If no
history of other tobacco use, select No. If unknown, select UNK. This field is optional.
[ADULT CANDIDATES]
Prior Cardiac Surgery (non-transplant): If the candidate had cardiac surgery prior to listing,
select Yes. If no prior cardiac surgery, select No. If Yes is selected, select all type(s) of surgery.

If the type of cardiac surgery is not listed, select Other, specify and enter the type of cardiac
surgery in the space provided.
CABG
Valve Replacement/Repair
Congenital
Left Ventricular Remodeling
Other, specify
Prior Lung Surgery (non-transplant): If the candidate had lung surgery prior to listing, select
Yes. If no prior lung surgery, select No. If Yes is selected, select all type(s) of surgery. If the
type of lung surgery is not listed, select Other, specify and enter the type of cardiac surgery in
the space provided. (These fields are optional for adult candidates only).
Pneumoreduction
Pneumothorax Surgery-Nodule
Pneumothorax Decortication
Lobectomy
Pneumonectomy
Left Thoracotomy
Right Thoracotomy
Other, specify
[PEDIATRIC CANDIDATES]
Prior Thoracic Surgery Other Than Previous Transplant: If the candidate had thoracic
surgery prior to listing, select Yes. If no prior thoracic surgery, select No. If Yes is selected,
select all type(s) of surgery. If the type of thoracic surgery is not listed, select Other, specify
and enter the type of thoracic surgery in the space provided.
If yes, number of prior sternotomies
If yes, number of prior thoracotomies
Prior Congenital Cardiac Surgery: If the candidate had prior surgery, select Yes. If not, select
No. If unknown, select UNK.
If Yes, Palliative Surgery: If the surgery was palliative, select Yes. If not, select No. If
unknown, select UNK.
If Yes, Corrective Surgery: If the surgery was corrective, select Yes. If not, select No. If
unknown, select UNK.