3 Thoracic Heart Adult Transplant Recipient Follow Up

Records
Adult Thoracic Transplant Recipient Follow-Up Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 10/31/2010
®
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 Discharge Date:
State of Permanent Residence:
Zip Code:

-

Provider Information
Recipient Center:
Followup Center:

Physician Name:
NPI#:

j Transplant Center
k
l
m
n
Follow-up Care Provided By:

j Non Transplant Center Specialty Physician
k
l
m
n
j Primary Care Physician
k
l
m
n
j Other Specify
k
l
m
n

Specify:

Donor Information
UNOS Donor ID #:
Donor Type:

Patient Status
Date: Last Seen, Retransplanted or
Death

j LIVING
k
l
m
n
Patient Status:

j DEAD
k
l
m
n
j RETRANSPLANTED
k
l
m
n

Primary Cause of Death:
Specify:

Contributory Cause of Death:
Specify:

Contributory Cause of Death:
Specify:

Hospitalizations:
Has the patient been hospitalized since
the last patient status date:
Number of Hospitalizations:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
ST=

Hospitalized for Rejection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Hospitalized for Infection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Noncompliance:
Was there evidence of noncompliance
with immunosuppression medication
during this follow-up period that
compromised the patient’s recovery:

Functional Status:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

j No Limitations
k
l
m
n
j Limited Mobility
k
l
m
n
Physical Capacity:

j Wheelchair bound or more limited
k
l
m
n
j Not Applicable (< 1 year old or hospitalized)
k
l
m
n

j Unknown
k
l
m
n

Working for income:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

If No, Not Working Due To:

j Working Full Time
k
l
m
n

j Working Part Time due to Demands of Treatment
k
l
m
n
j Working Part Time due to Disability
k
l
m
n
j Working Part Time due to Insurance Conflict
k
l
m
n
If Yes:

j Working Part Time due to Inability to Find Full Time
k
l
m
n
Work
j Working Part Time due to Patient Choice
k
l
m
n
j Working Part Time Reason Unknown
k
l
m
n

j Working, Part Time vs. Full Time Unknown
k
l
m
n

j Within One Grade Level of Peers
k
l
m
n
j Delayed Grade Level
k
l
m
n
Academic Progress:

j Special Education
k
l
m
n

j Not Applicable < 5 years old/ High School graduate or
k
l
m
n
GED
j Status Unknown
k
l
m
n

j Full academic load
k
l
m
n
j Reduced academic load
k
l
m
n

j Unable to participate in academics due to disease or
k
l
m
n
condition

j Not Applicable < 5 years old/ High School graduate or
k
l
m
n
GED

Academic Activity Level:

j Status Unknown
k
l
m
n

Primary Insurance at Follow-up:
Specify

Clinical Information
Height:

ft.

Weight:

lbs.

in.

cm

ST=

kg

ST=

kg/m2

BMI:

j Functioning n
k
l
m
n
j Failed
k
l
m

Graft Status:

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:

j Primary Non-Function
k
l
m
n
j Acute Rejection
k
l
m
n

Primary Cause of Graft Failure:

j Chronic Rejection/Atherosclerosis
k
l
m
n
j Other, Specify
k
l
m
n
Other, Specify:

Graft Function:
Heart:
Ejection Fraction:

Pacemaker:

ST=

%

j YES n
k
l
m
n
j NO n
k
l
m
j
k
l
m
UNK

Coronary Artery Disease:

Clinically Significant Events:

j YES n
k
l
m
n
j NO n
k
l
m
j
k
l
m
UNK
j YES n
k
l
m
n
j
k
l
m
j NO n
k
l
m
UNK

Post Transplant Events:
Drug Treated Hypertension:

j NO n
k
l
m
j YES n
k
l
m
n
j UNK
k
l
m

Bone Disease (Symptomatic):

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Chronic Liver Disease:

j NO n
k
l
m
j YES n
k
l
m
n
j UNK
k
l
m

Cataracts:

j NO n
k
l
m
j YES n
k
l
m
n
j UNK
k
l
m

Diabetes onset during the follow-up
period:

j NO n
k
l
m
j YES n
k
l
m
n
j UNK
k
l
m

Diabetes: If Yes, Insulin Dependent:

Renal Dysfunction:

j NO n
k
l
m
j YES n
k
l
m
n
j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

If Yes, Creatinine > 2.5 mg/dl:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Chronic Dialysis:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Renal Tx since Thoracic Tx:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Stroke:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Drug Treated Hyperlipidemia:

j NO n
k
l
m
j YES n
k
l
m
n
j UNK
k
l
m

j Yes, at least one episode treated with anti-rejection
k
l
m
n
agent
Did patient have any acute rejection
episodes during the follow-up period:

j Yes, none treated with additional anti-rejection agent
k
l
m
n
j No
k
l
m
n

c HBIG (Hepatitis B Immune Globulin)
d
e
f
g
c Flu Vaccine (Influenza Virus)
d
e
f
g
c Lamivudine (Epivir) (for treatment of Hepatitis B)
d
e
f
g
c Valacyclovir (Valtrex)
d
e
f
g

c Other, Specify
d
e
f
g
Specify:
Specify:

Other therapies:

j NO
k
l
m
j YES n
k
l
m
n

c Photopheresis
d
e
f
g
If Yes, check all that apply:

c Plasmapheresis
d
e
f
g
c Total Lymphoid Irradiation (TLI)
d
e
f
g

Immunosuppressive Information
Previous Validated Maintenance FollowUp Medications:
Previous Validated Maintenance FollowUp Medications:

j Yes, same as validated TRR form
k
l
m
n
Were any medications given during the
follow-up period for maintenance:

j Yes, same as previous validated report
k
l
m
n
j Yes, but different than previous validated report
k
l
m
n
j None given
k
l
m
n

Did the physician discontinue all
maintenance immunosuppressive
medications:

j NO
k
l
m
j YES n
k
l
m
n

Did the patient participate in any clinical
research protocol for
immunosuppressive medications:

j NO
k
l
m
j YES n
k
l
m
n

Specify:

Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Follow-Up Medications

For each of the immunosuppressant medications listed, check Previous Maintenance (Prev Maint), Current
Maintenance (Curr Maint) or Anti-rejection (AR) to indicate all medications that were prescribed for the
recipient during this follow-up period, and for what reason. If a medication was not given, leave the associated
box(es) blank.
Previous Maintenance (Prev Maint) includes all immunosuppressive medications given during the report
period, which covers the period from the last clinic visit to the current clinic visit, for varying periods of time
which may be either long-term or intermediate term with a tapering of the dosage until the drug is either
eliminated or replaced by another long-term maintenance drug (example: Prednisone, Cyclosporine,
Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any
immunosuppressive medications given to treat rejection episodes.
Current Maintenance (Curr Maint) includes all immunosuppressive medications given at the current clinic visit
to begin in the next report for varying periods of time which may be either long-term or intermediate term with a
tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug
(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This
does not include any immunosuppressive medications given to treat rejection episodes.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of
treating an acute rejection episode since the last clinic visit (example: Methylprednisolone, Atgam, OKT3, or
Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or from
Mycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR
immunosuppression, but should be listed under maintenance immunosuppression.
Note: The Anti-rejection field refers to any anti-rejection medications since the last clinic visit, not just
at the time of the current clinic visit.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal
antibodies), select Previous Maint, or Current Maint, or AR next to Other Immunosuppressive Medication field,
and enter the full name of the medication in the space provided. Do not list non-immunosuppressive
medications.

Prev Curr AR
Maint Maint
Steroids
(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Atgam (ATG)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

OKT3 (Orthoclone, Muromonab)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Thymoglobulin

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Simulect - Basiliximab

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Zenapax - Daclizumab

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Azathioprine (AZA, Imuran)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

EON (Generic Cyclosporine)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Gengraf (Abbott Cyclosporine)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Other generic Cyclosporine, specify brand:

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Neoral (CyA-NOF)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Sandimmune (Cyclosporine A)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

CellCept (Mycophenolate Mofetil; MMF)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Generic MMF (Generic CellCept)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Prograf (Tacrolimus, FK506)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Generic Tacrolimus (Generic Prograf)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Modified Release Tacrolimus FK506E (MR4)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Sirolimus (RAPA, Rapamycin, Rapamune)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Myfortic (Mycophenolate Sodium)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Other Immunosuppressive Medications
Prev
Maint

Curr
Maint

AR

Campath - Alemtuzumab (anti-CD52)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Cyclophosphamide (Cytoxan)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Leflunomide (LFL, Arava)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Methotrexate (Folex, PFS, Mexate-AQ,
Rheumatrex)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Other Immunosuppressive Medication, Specify

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Rituximab

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Prev
Maint

Curr
Maint

Everolimus (RAD, Certican)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Other Immunosuppressive Medication, Specify

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Investigational Immunosuppressive Medications
AR

UNOS View Only
Comments:

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