17 Thoracic Lung Pediatric Post 5

Records
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

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

Yes, Grade OP
Bronchiolitis Obliterans Syndrome:
Yes, Grade 1

Yes, Grade 2

Yes, Grade 3

UNK

cm

ST=

kg

ST=

Yes, Grade UNK

Unknown

Renal Dysfunction:

YES

NO

UNK

Chronic Dialysis:
YES

NO

UNK

YES

NO

UNK

Renal Tx since Thoracic Tx:

Most Recent Serum Creatinine:

Diabetes onset during the follow-up period:

If yes, insulin dependent:

Post Transplant Malignancy:

mg/dl

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

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=