18 Heart_Lung Transplant Candidate Registration_Form.xlsx

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