15 Liver Adullt Transplant candidate Registration Worksheet

Records
Adult Liver 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

Ventilator

Artifical Liver

Other Mechanism, Specify
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
If Yes:
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

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

Height:

ft.

in.

cm

ST=

Weight:
BMI:

lbs
kg/m

kg

2

ABO Blood Group:

Primary Diagnosis:
Specify:

Secondary Diagnosis:
Specify:

General Medical Factors:

No

Type I

Type II
Diabetes:
Type Other

Type Unknown

Diabetes Status Unknown

No dialysis

Hemodialysis

Peritoneal Dialysis
Dialysis:

CAVH: Continuous Arteriovenous Hemofiltration

CV VH: Continuous Venous/Venous Hemofiltration

Dialysis Status Unknown

Dialysis-Unknown Type was performed

No
Peptic Ulcer:
Yes, active within the last year

ST=

Yes, not active within the last year

Unknown

No

Yes, and documented Coronary Artery Disease
Angina:

Yes, with no documented Coronary Artery Disease

Yes, but Coronary Artery Disease unknown

Status Unknown

Drug Treated Systemic Hypertension:

Symptomatic Cerebrovascular Disease:

Symptomatic Peripheral Vascular Disease:

Drug Treated COPD:

Pulmonary Embolism:

Any previous Malignancy:

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
Specify Type:
Breast

Thyroid

Tongue/Throat/Larynx

Lung

Leukemia/Lymphoma

Liver

Hepatocellular Carcinoma

Other, specify
Specify:

Most Recent Serum Creatinine:

mg/dl

ST=

Liver Medical Factors

Variceal Bleeding within Last Two Weeks:

Previous Upper Abdominal Surgery:

Spontaneous Bacterial Peritonitis:

History of Portal Vein Thrombosis:

History of TIPSS:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK