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Adult Heart Transplant Candidate Registration 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.
Provider Information
Recipient Center:
Candidate Information
Organ Registered:
Last Name:
Date of Listing or Add:
MI:
First Name:
Previous Surname:
SSN:
Gender:
HIC:
DOB:
Male
State of Permanent Residence:
Permanent ZIP Code:
Is Patient waiting in permanent ZIP code:
-
YES
NO
UNK
Ethnicity/Race:
(select all origins that apply)
American Indian or Alaska Native
Asian
American Indian
Asian Indian/Indian Sub-Continent
Eskimo
Chinese
Aleutian
Filipino
Alaska Indian
Japanese
American Indian or Alaska Native: Other
Korean
American Indian or Alaska Native: Not Specified/Unknown
Vietnamese
Female
Asian: Other
Asian: Not Specified/Unknown
Black or African American
Hispanic/Latino
African American
Mexican
African (Continental)
Puerto Rican (Mainland)
West Indian
Puerto Rican (Island)
Haitian
Cuban
Black or African American: Other
Hispanic/Latino: Other
Black or African American: Not Specified/Unknown
Native Hawaiian or Other Pacific Islander
Hispanic/Latino: Not
Specified/Unknown
White
Native Hawaiian
European Descent
Guamanian or Chamorro
Arab or Middle Eastern
Samoan
North African (non-Black)
Native Hawaiian or Other Pacific Islander: Other
White: Other
Native Hawaiian or Other Pacific Islander: Not
Specified/Unknown
White: Not Specified/Unknown
U.S. CITIZEN
Citizenship:
RESIDENT ALIEN
NON-RESIDENT ALIEN, Year Entered US
Year of Entry to the U.S.
NONE
GRADE SCHOOL (0-8)
HIGH SCHOOL (9-12) or GED
Highest Education Level:
ATTENDED COLLEGE/TECHNICAL SCHOOL
ASSOCIATE/BACHELOR DEGREE
POST-COLLEGE GRADUATE DEGREE
N/A (< 5 YRS OLD)
UNKNOWN
IN INTENSIVE CARE UNIT
Medical Condition at time of listing:
HOSPITALIZED NOT IN ICU
NOT HOSPITALIZED
Patient on Life Support:
YES
NO
Extra Corporeal Membrane Oxygenation
Intra Aortic Balloon Pump
Prostaglandins
Intravenous Inotropes
Inhaled NO
Ventilator
Other Mechanism, Specify
Specify:
NONE
LVAD
Patient on Ventricular Assist Device:
RVAD
TAH
LVAD+RVAD
VAD Brand1:
Specify:
VAD Brand2:
Specify:
Functional Status:
No Limitations
Limited Mobility
Physical Capacity:
Wheelchair bound or more limited
Not Applicable (< 1 year old or hospitalized)
Unknown
Working for income:
YES
NO
UNK
If No, Not Working Due To:
Working Full Time
Working Part Time due to Demands of Treatment
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 Patient Choice
Working Part Time Reason Unknown
Working, Part Time vs. Full Time Unknown
Within One Grade Level of Peers
Delayed Grade Level
Academic Progress:
Special Education
Not Applicable < 5 years old/ High School graduate or GED
Status Unknown
Academic Activity Level:
Full academic load
Reduced academic load
Unable to participate in academics due to disease or condition
Not Applicable < 5 years old/ High School graduate or GED
Status Unknown
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 800978-4334 or by emailing [email protected].
Previous Pancreas Islet Infusion:
YES
NO
UNK
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information: AT LISTING
Height:
ft.
Weight:
BMI:
lbs
kg/m
2
ABO Blood Group:
Primary Diagnosis:
Specify:
General Medical Factors:
No
Diabetes:
Type I
Type II
in.
cm
ST=
kg
ST=
Type Other
Type Unknown
Diabetes Status Unknown
No dialysis
Hemodialysis
Dialysis:
Peritoneal Dialysis
Dialysis Status Unknown
Dialysis-Unknown Type was performed
No
Yes, active within the last year
Peptic Ulcer:
Yes, not active within the last year
Unknown
No angina
Stable angina - strenuous activity results in angina
Stable angina - ordinary physical activity results in angina
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
Unknown if angina present
Drug Treated Systemic Hypertension:
Symptomatic Cerebrovascular Disease:
YES
NO
UNK
YES
NO
UNK
Symptomatic Peripheral Vascular Disease:
Drug Treated COPD:
Pulmonary Embolism:
Any Previous Transfusions:
Any previous Malignancy:
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
Skin Melanoma
Skin Non-Melanoma
CNS Tumor
Genitourinary
Breast
Specify Type:
Thyroid
Tongue/Throat/Larynx
Lung
Leukemia/Lymphoma
Liver
Other, specify
Specify:
Most Recent Serum Creatinine:
Total Serum Albumin:
mg/dl
ST=
g/dl
ST=
Heart Medical Factors:
Sudden Death:
Antiarrhythmics:
Amiodarone:
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
Implantable Defibrillator:
Infection Requiring IV Drug Therapy within 2/wks prior to
listing:
YES
NO
UNK
YES
NO
UNK
Exercise Oxygen Consumption:
ml/min/kg
ST=
Most Recent Hemodynamics:
Inotropes/Vasodilators:
PA (sys) mm/Hg:
PA (dia) mm/Hg:
PA (mean) mm/Hg:
PCW (mean) mm/Hg:
CO L/min:
History of Cigarette Use:
YES
NO
0-10
11-20
21-30
If Yes, Check # pack years:
31-40
41-50
>50
Unknown pack years
0-2 months
3-12 months
Duration of Abstinence:
13-24 months
25-36 months
37-48 months
ST=
YES
NO
ST=
YES
NO
ST=
YES
NO
ST=
YES
NO
ST=
YES
NO
49-60 months
>60 months
Continues To Smoke
Unknown duration
Other Tobacco Use:
Prior Cardiac Surgery (non-transplant):
YES
NO
UNK
YES
NO
UNK
CABG
Valve Replacement/Repair
If yes, check all that apply:
Congenital
Left Ventricular Remodeling
Other, specify
Specify:
Prior Lung Surgery (non-transplant):
YES
NO
UNK
Pneumoreduction
Pneumothorax Surgery-Nodule
Pneumothorax Decortication
Lobectomy
If yes, check all that apply:
Pneumonectomy
Left Thoracotomy
Right Thoracotomy
Other, specify
Specify:
| File Type | application/pdf |
| Author | bryantpc |
| File Modified | 2011-11-28 |
| File Created | 2011-11-28 |