Form 17 Liver Adult Post 5 year Transplant Recipient Follow Up W

Records
Adult Liver Transplant Recipient Post 5-Year 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.

Recipient Information
Name:

DOB:

SSN:

Gender:

HIC:

Tx Date:

Previous Follow-Up:

Previous Px Stat
Date:

Transplant Recipient Registration

Transplant Discharge Date:
State of Permanent Residence:

Zip Code:

-

Provider Information
Recipient Center:
Followup Center:

Donor Information
UNOS Donor ID #:
Donor Type:

Patient Status
Date: Last Seen, Retransplanted or Death

LIVING
Patient Status:

DEAD

RETRANSPLANTED

Primary Cause of Death:
Specify:

Clinical Information

Graft Status:

Functioning

Failed

If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Date of Failure:
Contributory causes of graft failure:
Primary Graft Failure

Vascular Thrombosis

Biliary Tract Complication:

Denovo Hepatitis

Recurrent Hepatitis:

Recurrent Disease:

Acute Rejection:

Chronic Rejection:

Infection:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

Other, Specify:

Most Recent Serum Creatinine:

Post Transplant Malignancy:

Donor Related:

Recurrence of Pre-Tx Tumor:

De Novo Solid Tumor:

De Novo Lymphoproliferative disease and Lymphoma:

mg/dl

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

ST=