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Pediatric Thoracic 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.
Name:
DOB:
SSN:
Gender:
HIC:
Previous Follow-Up:
Tx Date:
Transplant Recipient Registration
Previous Px Stat Date:
Transplant Discharge Date:
State of Permanent Residence:
Zip Code:
-
Recipient Center:
Followup Center:
UNOS Donor ID #:
Donor Type:
Date: Last Seen, Retransplanted or Death
LIVING
Patient Status:
DEAD
RETRANSPLANTED
Primary Cause of Death:
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
Date of Measurement:
Height:
ft.
Weight:
BMI:
Graft Status:
in.
lbs.
kg/m
cm
ST=
kg
ST=
2
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 Graft Failure:
Primary Non-Function
Acute Rejection
Primary Cause of Graft Failure:
Chronic Rejection/Atherosclerosis
Other, Specify
Other, Specify:
Coronary Artery Disease Since Last Follow Up:
YES
NO
NO BOS
Bronchiolitis Obliterans Syndrome:
Yes, Grade OP
UNK
Yes, Grade 1
Yes, Grade 2
Yes, Grade 3
Yes, Grade UNK
Unknown
Renal Dysfunction:
YES
NO
UNK
Chronic Dialysis:
Renal Tx since Thoracic Tx:
YES
NO
UNK
YES
NO
UNK
Most Recent Serum Creatinine:
Diabetes onset during the follow-up period:
mg/dl
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
If yes, insulin dependent:
Post Transplant Malignancy:
Donor Related:
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
YES
NO
UNK
Recurrence of Pre-Tx Tumor:
De Novo Solid Tumor:
De Novo Lymphoproliferative disease and Lymphoma:
ST=
| File Type | application/pdf |
| Author | bryantpc |
| File Modified | 2011-11-28 |
| File Created | 2011-11-28 |