6 Heart Transplant Candidate Registration_Form.xlsx

TCR - Heart - Adult				TCR - Heart - Pediatric
Fields to be completed by members				Fields to be completed by members
Form Section	Field Label	Notes		Form Section	Field Label	Notes
1-Provider Information	Transplant Center Code	Display Only - Cascades from Waitlist		2-Provider Information(1)	Transplant Center Code	Display Only - Cascades from Waitlist
1-Provider Information	Transplant Center Type://Recipient Center	Display Only - Cascades from Waitlist		1-Provider Information(2)	Transplant Center Type://Recipient Center	Display Only - Cascades from Waitlist
2-Candidate Information	Organ Registered:	Display Only - Cascades from Waitlist		2-Candidate Information(2)	Organ Registered:	Display Only - Cascades from Waitlist
2-Candidate Information	Date of Listing or Add:	Display Only - Cascades from Waitlist		2-Candidate Information(3)	Date of Listing or Add:	Display Only - Cascades from Waitlist
2-Candidate Information	Last Name:	Cascades from Waitlist		2-Candidate Information(4)	Last Name:	Cascades from Waitlist
2-Candidate Information	First Name:	Cascades from Waitlist		2-Candidate Information(5)	First Name:	Cascades from Waitlist
2-Candidate Information	Middle Initial://MI:	Not required		2-Candidate Information(6)	Middle Initial://MI:	Not required
2-Candidate Information	Previous Surname:	Not required		2-Candidate Information(11)	Previous Surname:	Not required
2-Candidate Information	SSN:	Display Only - Cascades from Waitlist		2-Candidate Information(1 & 8)	SSN:	Display Only - Cascades from Waitlist
2-Candidate Information	Gender:	Cascades from Waitlist		2-Candidate Information(10)	Gender:	Cascades from Waitlist
2-Candidate Information	HIC:	Not required		2-Candidate Information(8)	HIC:	Not required
2-Candidate Information	Date of Birth://DOB:	Cascades from Waitlist		2-Candidate Information(9)	Date of Birth://DOB:	Cascades from Waitlist
2-Candidate Information	State of Permanent Residence:	Cascades from Waitlist		2-Candidate Information(12)	State of Permanent Residence:	Cascades from Waitlist
2-Candidate Information	Permanent ZIP Code:	Cascades from Waitlist		2-Candidate Information(13)	Permanent ZIP Code:	Cascades from Waitlist
2-Candidate Information	Ethnicity/Race:	Cascades from Waitlist		2-Candidate Information(16)	Ethnicity/Race:	Cascades from Waitlist
2-Candidate Information	Citizenship:			2-Candidate Information(17)	Citizenship:
2-Candidate Information	Year of Entry to the U.S.			2-Candidate Information(19)	Year of Entry to the U.S.
2-Candidate Information	Year of Entry to the U.S Status//ST=			2-Candidate Information(18)	Year of Entry to the U.S Status//ST=
2-Candidate Information	Country of Permanent Residence			2-Candidate Information(18)	Country of Permanent Residence
2-Candidate Information	Highest Education Level:			2-Candidate Information(19)	Highest Education Level:
3-Patient Status	Patient on Life Support:			3-Patient Status(2)	Patient on Life Support:
3-Patient Status	Life Support://Extra Corporeal Membrane Oxygenation			3-Patient Status(3)	Life Support://Extra Corporeal Membrane Oxygenation
3-Patient Status	Life Support://Intra Aortic Balloon Pump			3-Patient Status(4)	Life Support://Intra Aortic Balloon Pump
3-Patient Status	Life Support://Prostaglandins			3-Patient Status(5)	Life Support://Prostaglandins
3-Patient Status	Life Support://Intravenous Inotropes			3-Patient Status(6)	Life Support://Intravenous Inotropes
3-Patient Status	Life Support://Inhaled NO			3-Patient Status(7)	Life Support://Inhaled NO
3-Patient Status	Life Support://Ventilator			3-Patient Status(7)	Life Support://Ventilator
3-Patient Status	Life Support://Other Mechanism, Specify			3-Patient Statu(8)	Life Support://Other Mechanism, Specify
3-Patient Status	Life Support:Other Mechanism//Specify:			3-Patient Status(9)	Life Support:Other Mechanism//Specify:
3-Patient Status	Life Support://Patient on Ventricular Assist Device:			3 -Patient Status(26)	Life Support://Patient on Ventricular Assist Device:
3-Patient Status	Life Support://VAD Brand1:			3 -Patient Status(27)	Life Support://VAD Brand1:
3-Patient Status	Life Support://VAD Brand2:			3 -Patient Status(28)	Life Support://VAD Brand2:
3-Patient Status	Life Support:VAD Brand1//Specify:			3 -Patient Status(29)	Life Support:VAD Brand1//Specify:
3-Patient Status	Life Support:VAD Brand2//Specify:			3 -Patient Status(29)	Life Support:VAD Brand2//Specify:
3-Patient Status	Functional Status:			3-Patient Status(11)	Functional Status:
3-Patient Status	Working for income:			3-Patient Status(12)	Cognitive Development:
3-Patient Status	Previous Transplant//Organ	Display Only - Cascades from Database		3-Patient Status(12)	Motor Development:
3-Patient Status	Previous Transplant//Date	Display Only - Cascades from Database		3-Patient Status(13)	Working for income:
3-Patient Status	Previous Transplant//Graft Fail Date	Display Only - Cascades from Database		3-Patient Status(16)	Academic Progress:
3-Patient Status	Previous Pancreas Islet Infusion			3-Patient_Status (17)	Academic Activity Level:
4-Source of Payment	Source of Payment//Primary:				Previous Transplant//Organ	Display Only - Cascades from Database
4-Source of Payment	Foreign Government//Specify:				Previous Transplant//Date	Display Only - Cascades from Database
5-Clinical Information	Height in cm://Height:				Previous Transplant//Graft Fail Date	Display Only - Cascades from Database
5-Clinical Information	Height Status//ST=	Value or status is reported, not both		4-Source of Payment(1)	Source of Payment//Primary:
5-Clinical Information	Height Growth percentiles//%ile	Calculated for display only		4-Source of Payment(2)	Foreign Government//Specify:
5-Clinical Information	Weight in kg://Weight:			5-Clinical Information(1)	Date of Measurement:
5-Clinical Information	Weight Status//ST=	Value or status is reported, not both		5-Clinical Information(1)	Height in cm://Height:
5-Clinical Information	Weight Growth percentiles//%ile	Calculated for display only		5-Clinical Information(2)	Height Status//ST=	Value or status is reported, not both
5-Clinical Information	BMI:	Display Only - Cascades from Database		5-Clinical Information(2)	Height Growth percentiles//%ile	Calculated for display only
5-Clinical Information	BMI://%ile	Calculated for display only		5-Clinical Information(3)	Weight in kg://Weight:
5-Clinical Information	ABO Blood Group:	Display Only - Cascades from Waitlist		5-Clinical Information(4)	Weight Status//ST=	Value or status is reported, not both
5-Clinical Information	Primary Diagnosis:			5-Clinical Information	Weight Growth percentiles//%ile	Calculated for display only
5-Clinical Information	Primary Diagnosis//Specify:			5-Clinical Information(5)	BMI:	Display Only - Cascades from Database
6-General Medical Factors	Diabetes:			5-Clinical Information(4)	BMI://%ile	Calculated for display only
6-General Medical Factors	Dialysis:			5-Clinical Information(5)	ABO Blood Group:	Display Only - Cascades for Waitlist
6-General Medical Factors	Symptomatic Cerebrovascular Disease:			5-Clinical Information(7)	Primary Diagnosis:
6-General Medical Factors	Any previous Malignancy:			5-Clinical Information(8)	Primary Diagnosis//Specify:
6-General Medical Factors	Any previous Malignancy//Specify Type:			6-General Medical Factors(1)	Diabetes:
6-General Medical Factors	Any previous Malignancy//Specify:			6-General Medical Factors(2)	Dialysis:
6-General Medical Factors	Most Recent Serum Creatinine:			6-General Medical Factors(6)	Symptomatic Cerebrovascular Disease:
6-General Medical Factors	Most Recent Serum Creatinine//ST=	Value or status is reported, not both		6-General Medical Factors	Any previous Malignancy:
7-Heart Medical Factors	Implantable Defibrillator:			6-General Medical Factors(14)	Any previous Malignancy//Specify Type:
7-Heart Medical Factors	Exercise Oxygen Consumption:			6-General Medical Factors	Any previous Malignancy//Specify:
7-Heart Medical Factors	Exercise Oxygen Consumption//ST=	Value or status is reported, not both		6-General Medical Factors(13)	Most Recent Serum Creatinine:
8-Heart/Lung Medical Factors	PA (sys) mm/Hg:			6-General Medical Factors(14)	Most Recent Serum Creatinine//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	PA (sys) mm/Hg//ST=	Value or status is reported, not both		6-General Medical Factors(15)	Total Serum Albumin:
8-Heart/Lung Medical Factors	PA (sys) mm/Hg Inotropes/Vasodilators			6-General Medical Factors(16)	Total Serum Albumin//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	PA (dia) mm/Hg:			13-Heart Medical Factors(1)	Sudden Death:
8-Heart/Lung Medical Factors	PA (dia) mm/Hg//ST=	Value or status is reported, not both		7-Heart Medical Factors(4)	Implantable Defibrillator:
8-Heart/Lung Medical Factors	PA (dia) mm/Hg Inotropes/Vasodilators			7-Heart Medical Factors(5)	Exercise Oxygen Consumption:
8-Heart/Lung Medical Factors	PA (mean) mm/Hg:			7-Heart Medical Factors(6)	Exercise Oxygen Consumption//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	PA (mean) mm/Hg//ST=	Value or status is reported, not both		8-Heart/Lung Medical Factors(1)	PA (sys) mm/Hg:
8-Heart/Lung Medical Factors	PA (mean) mm/Hg Inotropes/Vasodilators			8-Heart/Lung Medical Factors(2)	PA (sys) mm/Hg//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	PCW (mean) mm/Hg:			8-Heart/Lung Medical Factors(3)	PA (sys) mm/Hg Inotropes/Vasodilators
8-Heart/Lung Medical Factors	PCW (mean) mm/Hg//ST=	Value or status is reported, not both		8-Heart/Lung Medical Factors(4)	PA (dia) mm/Hg:
8-Heart/Lung Medical Factors	PCW (mean) mm/Hg Inotropes/Vasodilators			8-Heart/Lung Medical Factors(5)	PA (dia) mm/Hg//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	CO L/min:			8-Heart/Lung Medical Factors(6)	PA (dia) mm/Hg Inotropes/Vasodilators
8-Heart/Lung Medical Factors	CO L/min//ST=	Value or status is reported, not both		8-Heart/Lung Medical Factors(7)	PA (mean) mm/Hg:
8-Heart/Lung Medical Factors	CO L/min Inotropes/Vasodilators			8-Heart/Lung Medical Factors(8)	PA (mean) mm/Hg//ST=	Value or status is reported, not both
8-Heart/Lung Medical Factors	History of Cigarette Use:			8-Heart/Lung Medical Factors(9)	PA (mean) mm/Hg Inotropes/Vasodilators
8-Hearrt/Lung Medical Condition	Duration of Abstinence:			8-Heart/Lung Medical Factors(10)	PCW (mean) mm/Hg:
8-Heart/Lung Medical Condition	Prior Cardiac Surgery (non-transplant):			8-Heart/Lung Medical Factors(11)	PCW (mean) mm/Hg//ST=	Value or status is reported, not both
8-Heart/Lung Medical Condition	If yes, check all that apply:			8-Heart/Lung Medical Factors(12)	PCW (mean) mm/Hg Inotropes/Vasodilators
8-heart/Lung Medical Condition	Prior Cardiac Surgery type//Specify:			8-Heart/Lung Medical Factors(13)	CO L/min:
				8-Heart/Lung Medical Factors(14)	CO L/min//ST=	Value or status is reported, not both
	Public Burden Statement			8-Heart/Lung Medical Factors(15)	CO L/min Inotropes/Vasodilators
				8-Heart/Lung Medical Factors(16)	History of Cigarette Use:
				8-Hearrt/Lung Medical Condition	Duration of Abstinence:
				8-Heart/Lung Medical Condition	Prior Thoracic Surgery other than prior transplant:
				8-Heart/Lung Medical Condition	Prior Thoracic Surgery//If yes, number of prior sternotomies:
				8-Heart/Lung Medical Condition	Prior Thoracic Surgery//If yes, number of prior thoracotomies:
				8-Heart/Lung Medical Condition	Prior Thoracic Surgery//Prior congenital cardiac surgery:
				8-Heart/Lung Medical Condition	Prior congenital cardiac surgery//If yes, palliative surgery:
				8-Heart/Lung Medical Condition	Prior congenital cardiac surgery//If yes, corrective surgery:
				8-Heart/Lung Medical Condition	Prior congenital cardiac surgery//If yes, single ventricular physiology:
					Public Burden Statement