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DEMOGRAPHICS
Identifier:
Center:
CENTER INFORMATION
Center:
*
PATIENT INFORMATION
Patient Identifier:
*
Date of Birth:
*
mm/dd/yyyy
Gender:
*
Male
Female
Race:
African-American or Black
Asian
Indian Subcontinent
Pacific Islander
Mid-East/Arabian
White
Other/None of the Above
DIAGNOSIS INFORMATION
Date of first heart failure diagnosis/assessment at this center:
*
mm/dd/yyyy
Was patient previously diagnosed at another institution:
*
Yes
No
Unknown
mm/dd/yyyy
Primary Diagnosis:
*
ARVD
Cardiac tumor
CHD
CM mixed
CM other
DCM: chemotherapy-induced
DCM: conduction defect
DCM: familial
DCM: genetic
DCM: idiopathic
DCM: ischemic/Kawasaki
DCM: ischemic/other
DCM: metabolic, specify
DCM: neuromuscular
DCM: other
DCM: s/p myocarditis
HCM: familial
HCM: idiopathic
HCM: metabolic
HCM: neuromuscular
HCM: other
HCM: syndromic
Myocarditis
RCM: chemotherapy-induced
RCM: idiopathic
RCM: metabolic, specify
RCM: other
RCM: s/p radiation
Other, specify
Specify:
*
CHD (check all that apply):
*
ccTGA
complete AVSD
dTGA
Ebstein's
Heterotaxy
HLHS
Kawasaki Disease
Left heart valvar/structural hypoplasia
PA-IVS
Single V
TOF/TOF variant
Tricuspid atresia
Truncus
VSD/ASD
Other, specify
Unknown
Specify:
*
ISHLT PEDIATRIC HEART FAILURE REGISTRY
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