LIVER CANDIDATE SUMMARY



Heart Candidate SummaryKidney FORMCHECKBOX Liver FORMCHECKBOX Other: FORMTEXT ?????OSOTC Patient Number: FORMTEXT ? ??PATIENT DEMOGRAPHICSInitials: FORMTEXT ?????Birth Date: FORMTEXT ?????Height: FORMTEXT ????? Weight: FORMTEXT ?????Gender: M FORMCHECKBOX F FORMCHECKBOX ABO: A FORMCHECKBOX B FORMCHECKBOX AB FORMCHECKBOX O FORMCHECKBOX Race: FORMTEXT ?????Transplant#: FORMTEXT ?????Patient StatusMedical Diagnosis: FORMTEXT ?????UNOS Status: 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4 FORMCHECKBOX 5 FORMCHECKBOX 6 FORMCHECKBOX NYHA Functional Class: FORMTEXT ?????Mechanical circulatory support: Yes FORMCHECKBOX No FORMCHECKBOX Date: FORMTEXT ?????Device: FORMTEXT ?????Complications: FORMTEXT ?????PATIENT CARE LOCATION: FORMCHECKBOX Outpatient FORMCHECKBOX Inpatient not in ICU or special care unit FORMCHECKBOX Inpatient in ICU or special care unitMEDICAL HISTORY (Co-morbidities, AICD, infection, etc.):ICD: FORMTEXT ?????CRT: FORMTEXT ????? FORMTEXT ?????SURGICAL HISTORY (Previous transplant surgery, CABG, valve repair, stent, etc.): FORMTEXT ?????Right Heart CatheterizationDateHRBPRARVPA (S/D/M)PCWPTPGPVRCO/CIDrug? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Echocardiogram ResultsDate: FORMTEXT ???? FORMTEXT ????Not Done FORMCHECKBOX EFEDDMRTRRVComments FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Cardiopulmonary Exercise TestDate: FORMTEXT ???? FORMTEXT ????Not Done FORMCHECKBOX Peak VO2: FORMTEXT ?????%Predicted for Age: FORMTEXT ?????VE/VCO2: FORMTEXT ?????RER: FORMTEXT ?????Pulmonary Function TestDate: FORMTEXT ???? FORMTEXT ????Not Done FORMCHECKBOX FVC%FVCFEV1%FEV1%DLCOpHpO2pCO2HCO3FiO2Sat FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Cancer Screening ResultsMALIGNANCY HISTORY: FORMTEXT ?????Laboratory ResultsDate: FORMTEXT ???? FORMTEXT ????Not Done FORMCHECKBOX WBC:Hgb:HCT:Plts:PT:INR: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Sodium:Potassium:BUN:Creatinine:Creat.Clear:Renal Failure: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT T.Bili:Alk Phos:AST:ALT:T.Protein:Albumin: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TSH:Cholesterol:Triglycerides:HDL: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Psychosocial Evaluation/Quality of Life(Support system, informed consent, attitude about transplant, aftercare, complications, etc.): FORMTEXT ?????Ohio Medicaid InsuranceThe Ohio Medicaid Required Information Form should be submitted along with this summary.Select Type: Standard Medicaid FORMCHECKBOX Medicaid Managed Care Plan FORMCHECKBOX ................
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