7b Heart Pediatric Transplant Candidate Registration

Records
Pediatric 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
Asian: Other

Female

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

ATTENDED COLLEGE/TECHNICAL SCHOOL
Highest Education Level:
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:

Definite Cognitive delay/impairment

Probable Cognitive delay/impairment
Cognitive Development:

Questionable Cognitive delay/impairment

No Cognitive delay/impairment

Not Assessed

Definite Motor delay/impairment

Probable Motor delay/impairment
Motor Development:

Questionable Motor delay/impairment

No Motor delay/impairment

Not Assessed

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

Full academic load

Reduced academic load
Academic Activity Level:

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

Date of Measurement:

Height:

ft.

Weight:
BMI:

in.

lbs
kg/m

2

ABO Blood Group:

Primary Diagnosis:
Specify:

General Medical Factors:

No

Type I

Type II
Diabetes:
Type Other

Type Unknown

Diabetes Status Unknown

No dialysis
Dialysis:

Hemodialysis

Peritoneal Dialysis

cm

ST=

kg

ST=

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:

Symptomatic Peripheral Vascular Disease:

Drug Treated COPD:

Pulmonary Embolism:

Any Previous Transfusions:

Any previous Malignancy:

Specify Type:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

Skin Melanoma

Skin Non-Melanoma

CNS Tumor

Genitourinary

Breast

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:

Implantable Defibrillator:

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

Exercise Oxygen Consumption:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

ml/min/kg

ST=

Most Recent Hemodynamics:
PA (sys) mm/Hg:

PA (dia) mm/Hg:

Inotropes/Vasodilators:

ST=

YES

NO

ST=

YES

NO

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

13-24 months

25-36 months
Duration of Abstinence:

37-48 months

49-60 months

>60 months

Continues To Smoke

Unknown duration

Other Tobacco Use:

Prior Thoracic Surgery other than prior transplant:

YES

NO

UNK

YES

NO

UNK

ST=

YES

NO

ST=

YES

NO

ST=

YES

NO

Unknown if there were prior sternotomies

0

1

2
If yes, number of prior sternotomies:
3

4

5+

Unknown number of prior sternotomies

Unknown if there were prior thoracotomies

0

1

2
If yes, number of prior thoracotomies:
3

4

5+

Unknown number of prior thoracotomies

Prior congenital cardiac surgery:

If yes, palliative surgery:

If yes, corrective surgery:

If yes, single ventricular physiology:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK