1 Living Donor Follow-up

Records
Living Donor Follow-Up Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2011
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 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.

Donor ID:
Provider Information
Recipient Center:
Followup Center:

Donor Information
Name:

DOB:

Transplant Date:
SSN:

Gender:

Donor ID:

Recovery Date:

Organ:

Donor Status
Date of Initial Discharge:

Date of last contact
or death:
Most Recent Donor
Status since:

Living

Attempts to Collect:

Cause of Death:
Specify:

Functional Status:

No Limitations
Physical Capacity:
Limited Mobility

Wheelchair bound or more limited
Unknown

Working for Income:

YES

NO

UNK

Disability
Insurance Conflict
Inability to Find Work
Donor Choice - Homemaker
If No, Not Working Due To:
Donor Choice - Student Full Time/Part Time
Donor Choice - Retired
Donor Choice - Other
Unknown

Working Full Time
Working Part Time due to Disability
Working Part Time due to Insurance Conflict
If Yes:

Working Part Time due to Inability to Find Full Time Work
Working Part Time due to Donor Choice
Working Part Time Reason Unknown
Working, Part Time vs. Full Time Unknown

Clinical Information
Current weight:

lb

Were any of the following procedures performed since:

kg

ST=

Not Done
Yes, Normal Results
CAT Scan:
Yes, Specify Results
Unknown
Specify:

Not Done
Yes, Normal Results
MRI:
Yes, Specify Results
Unknown
Specify:

Not Done
Yes, Normal Results
Ultrasound:
Yes, Specify Results
Unknown
Specify:

Liver Clinical Information
Most Recent Values Since:
Total Bilirubin:
SGOT/AST:
SGPT/ALT:
Alkaline Phosphatase:
Serum Albumin:

mg/dl

ST=

U/L

ST=

U/L

ST=

units/L

ST=

g/dl

ST=

Serum Creatinine:

mg/dl

ST=

INR:

ST=

Kidney Clinical Information
Most Recent Values Since:
Serum Creatinine:

Blood Pressure Systolic:
Blood Pressure Diastolic:

Donor Developed Hypertension Requiring
Medication:

mg/dl

ST=

mm/Hg

ST=

mm/Hg

ST=

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

Urinalysis:

Positive
Negative
Urine Protein:
Not Done
Unknown
or
Protein-Creatinine Ratio:

Maintenance Dialysis:

If Yes, Date First Dialyzed:

Diabetes:

Insulin
Treatment:
Oral Hypoglycemic Agent

Diet

Lung Clinical Information

No change in activity level
Mild decrease in activity level
Moderate decrease in activity level
Activity Level:
Severe decrease in activity level
Increase in activity level
Unknown

Mild
Moderate
Chronic Incisional Pain:
Severe
Unknown

Complications
Has the donor been readmitted since:

YES

NO

UNK

If Yes, Date of First Readmission:

ST=

Specify Reason for First Readmission:

Kidney Complications since:

YES

NO

UNK

Added to UNOS TX candidate waiting list
If Yes:
Other, specify
Specify:

Liver Complications since:

YES

NO

UNK

Bile Leak
Hepatic Resection
Abscess
If Yes:
Liver Failure
Added to UNOS TX candidate waiting list
Other, specify
Specify:

Complications since:

Specify:

Recipient Information
Name:
Transplant Date:
SSN:

UNOS View Only
Comments:

YES

NO