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UNOS_Employees
PATIENT REGISTRATION
PRE-TX
TRANSPLANT
DONOR
DISCHARGE
PROVIDER INFORMATION:
Transplant Hospital Name and Provider Number:
PATIENT INFORMATION:
Chart Number:
9IS Number:
Last Name:
(optional)
First Name:
(optional)
Middle Initial:
(optional)
Date of Birth:
or
Age at Transplant
Gender:
Male
Female
ABO Blood Group:
A1
A1B
A2
A2B
AB
B
O
Diagnosis:
ABCA3 TRANSPORTER MUTATION
ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS
ALPHA - 1 - ANTITRYPSIN DEFICIENCY
ALVEOLAR PROTEINOSIS
AMYLOIDOSIS
ARDS/PNEUMONIA
ARRHYTHMOGENIC RIGHT VENTRICULAR DYSPLASIA/CARDIOMYOPATHY
BRONCHIECTASIS
BRONCHIOLOALVEOLAR CARCINOMA (BAC)
BRONCHOPULMONARY DYSPLASIA
CANCER
CARCINOID TUMORLETS
CHRONIC PNEUMONITIS OF INFANCY
COMMON VARIABLE IMMUNE DEFICIENCY
CONGENITAL HEART DEFECT - PRIOR SURGERY UNKNOWN
CONGENITAL HEART DEFECT - WITH SURGERY
CONGENITAL HEART DEFECT - WITHOUT SURGERY
CONGENITAL MALFORMATION
CONSTRICTIVE BRONCHIOLITIS
COPD/EMPHYSEMA
CORONARY ARTERY DISEASE
CREST - PULMONARY HYPERTENSION
CREST - RESTRICTIVE
CYSTIC FIBROSIS
DILATED MYOPATHY: ADRIAMYCIN
DILATED MYOPATHY: ALCOHOLIC
DILATED MYOPATHY: FAMILIAL
DILATED MYOPATHY: IDIOPATHIC
DILATED MYOPATHY: ISCHEMIC
DILATED MYOPATHY: MYOCARDITIS
DILATED MYOPATHY: OTHER SPECIFY
DILATED MYOPATHY: POST PARTUM
DILATED MYOPATHY: VIRAL
EHLERS-DANLOS SYNDROME
EISENMENGER'S SYN: ATRIAL SEPTAL DEFECT
EISENMENGER'S SYN: MULTI CONGENITAL ANOMALIES
EISENMENGER'S SYN: OTHER SPECIFY
EISENMENGER'S SYN: PDA
EISENMENGER'S SYN: VSD
EOSINOPHILIC GRANULOMA
FIBROCAVITARY LUNG DISEASE
FIBROSING MEDIASTINITIS
GRAFT-VS-HOST DISEASE (GVHD)
GRANULOMATOUS LUNG DISEASE
HEART RE-TX/GF: ACUTE REJECTION
HEART RE-TX/GF: CHRONIC REJECTION
HEART RE-TX/GF: CORONARY ARTERY DISEASE
HEART RE-TX/GF: HYPERACUTE REJECTION
HEART RE-TX/GF: NON-SPECIFIC
HEART RE-TX/GF: OTHER SPECIFY
HEART RE-TX/GF: PRIMARY FAILURE
HEART RE-TX/GF: RESTRICTIVE/CONSTRICTIVE
HEART/LUNG RE-TX/GF: PRIMARY FAILURE
HERMANSKY PUDLAK SYNDROME
HYPERSENSITIVITY PNEUMONITIS
HYPERTROPHIC CARDIOMYOPATHY
HYPOGAMMAGLOBULINEMIA
IDIOPATHIC PULMONARY HEMOSIDEROSIS
IIP: ACUTE INTERSTITIAL PNEUMONIA
IIP: BOOP/COP
IIP: DESQUAMATIVE INTERSTITIAL PNEUMONIA
IIP: IDIOPATHIC PULMONARY FIBROSIS (IPF)
IIP: LYMPHOCYTIC INTERSTITIAL PNEUMONIA (LIP)
IIP: NONSPECIFIC INTERSTITIAL PNEUMONIA
IIP: RESPIRATORY BRONCHIOLITIS
INHALATION BURNS/TRAUMA
KARTAGENER'S SYNDROME
LUNG RE-TX/GF: ACUTE REJECTION
LUNG RE-TX/GF: NON-SPECIFIC
LUNG RE-TX/GF: OBLITERATIVE BRONCHIOLITIS-OBSTRUCTIVE
LUNG RE-TX/GF: OBLITERATIVE BRONCHIOLITIS-RESTRICTIVE
LUNG RE-TX/GF: OBSTRUCTIVE
LUNG RE-TX/GF: OTHER SPECIFY
LUNG RE-TX/GF: PRIMARY GRAFT FAILURE
LUNG RE-TX/GF: RESTRICTIVE
LUPUS
LYMPHANGIOLEIOMYOMATOSIS
MIXED CONNECTIVE TISSUE DISEASE
MUSCULAR DYSTROPHY: OTHER SPECIFY
OBLITERATIVE BRONCHIOLITIS (NON-RETRANSPLANT)
OBSTRUCTIVE LUNG DISEASE
OCCUPATIONAL LUNG DISEASE OTHER SPECIFY
OTHER - SPECIFY
PARANEOPLASTIC PEMPHIGUS ASSOCIATED CASTLEMAN'S DISEASE
POLYMYOSITIS
PORTOPULMONARY HYPERTENSION
PRIMARY CILIARY DYSKINESIA
PULMONARY CAPILLARY HEMANGIOMATOSIS
PULMONARY FIBROSIS OTHER SPECIFY CAUSE
PULMONARY HYALINIZING GRANULOMA
PULMONARY HYPERTENSION/PULMONARY ARTERIAL HYPERTENSION
PULMONARY LYMPHANGIECTASIA (PL)
PULMONARY TELANGIECTASIA - PULMONARY HYPERTENSION
PULMONARY TELANGIECTASIA - RESTRICTIVE
PULMONARY THROMBOEMBOLIC DISEASE
PULMONARY VASCULAR DISEASE
PULMONARY VENO-OCCLUSIVE DISEASE
PULMONIC STENOSIS
RESTRICTIVE MYOPATHY: AMYLOIDOSIS
RESTRICTIVE MYOPATHY: ENDOCARDIAL FIBROS
RESTRICTIVE MYOPATHY: IDIOPATHIC
RESTRICTIVE MYOPATHY: OTHER SPECIFY
RESTRICTIVE MYOPATHY: SARCOIDOSIS
RESTRICTIVE MYOPATHY: SEC TO RADIAT/CHEM
RHEUMATOID DISEASE
RIGHT HYPOPLASTIC LUNG
SARCOIDOSIS
SCLERODERMA - PULMONARY HYPERTENSION
SCLERODERMA - RESTRICTIVE
SECONDARY PULMONARY FIBROSIS (SPECIFY CAUSE)
SECONDARY PULMONARY HYPERTENSION
SHWACHMAN-DIAMOND SYNDROME
SILICOSIS
SJOGREN'S SYNDROME
SURFACTANT PROTEIN B DEFICIENCY
SURFACTANT PROTEIN C DEFICIENCY
TERATOMA
THROMBOEMBOLIC PULMONARY HYPERTENSION
TUBEROUS SCLEROSIS
VALVULAR HEART DISEASE
WEGENER'S GRANULOMA - BRONCHIECTASIS
WEGENER'S GRANULOMA - RESTRICTIVE
Previous Transplant:
YES
NO
DONOR INFORMATION:
Donor Date of Birth:
or
Donor Age at Recovery:
Donor ABO Blood Group:
A
A1
A1B
A2
A2B
AB
B
O
Donor Gender:
Male
Female
Donor Type:
Cadaveric
Living
TRANSPLANT INFORMATION:
Transplant Date:
Procedure Type:
Ortho Heart
Hetero Heart
Heart Lung
Single Left Lung
Single Right Lung
Bilateral Sequential Lung
En-Bloc Double Lung
Lobe, Right
Lobe, Left
Single Left Lung, Right Lobe
Single Right Lung, Left Lobe
Lobe, Other Specify
Split Left Lung
Split Right Lung
Ischemia Time:
(optional)
Heart, Heart-Lung:
min
ST=
Missing
Unknown
N/A
Not Done
Left Lung:
min
ST=
Missing
Unknown
N/A
Not Done
Right Lung:
min
ST=
Missing
Unknown
N/A
Not Done
PATIENT DISCHARGE INFORMATION:
Patient Status:
LIVING
DEAD
RETRANSPLANTED
Date of Visit:
Cause of Death:
UNKNOWN
OTHER SPECIFY
GRAFT FAILURE: PRIMARY FAILURE
GRAFT FAILURE: REJECTION- HYPERACUTE
GRAFT FAILURE: REJECTION- ACUTE
GRAFT FAILURE: REJECTION- CHRONIC
GRAFT FAILURE: TECHNICAL
GRAFT FAILURE: GRAFT INFECTION
GRAFT FAILURE: RECURRENT DISEASE
GRAFT FAILURE: NON-SPECIFIC
INFECTION: BACTERIAL SEPTICEMIA
INFECTION: BACTERIAL PNEUMONIA
INFECTION: BACTERIAL- OTHER SPECIFY
INFECTION: VIRAL- CYTOMEGALOVIRUS (CMV)
INFECTION: VIRAL- HEPATITIS
INFECTION: VIRAL-SEPTICEMIA
INFECTION: VIRAL- OTHER SPECIFY
INFECTION: FUNGAL- ASPERGILLUS
INFECTION: FUNGAL- OTHER SPECIFY
INFECTION: PROTOZOAL
INFECTION: MIXED OTHER SPECIFY
INFECTION: OTHER SPECIFY
CARDIOVASCULAR: MYOCARDIAL INFARCTION
CARDIOVASCULAR: CARDIAC ARREST
CARDIOVASCULAR: ARTERIAL EMBOLISM
CARDIOVASCULAR: VENTRICULAR FAILURE
CARDIOVASCULAR: CORONARY ARTERY DISEASE
CARDIOVASCULAR: ATHEROSCLEROSIS
CARDIOVASCULAR: RHYTHM DISORDER
CARDIOVASCULAR: CARDITIS
CARDIOVASCULAR: AORTIC ANEURYSM
CARDIOVASCULAR: CARDIOGENIC SHOCK
CARDIOVASCULAR: OTHER SPECIFY
PULM: DEHISCENCE
PULM: BRONCHIOLITIS
PULM: PRIMARY PULMONARY HYPERTENSION
PULM: PULMONARY EMBOLISM
PULM: RESPIRATORY FAILURE
PULM: ACUTE RESPIRATORY DISTRESS DISEASE
PULM: OTHER SPECIFY
CEREBROVASCULAR: STROKE
CEREBROVASCULAR: HEMORRHAGE (NON-STROKE)
CEREBROVASCULAR: BRAIN ANOXIA
CEREBROVASCULAR: DEGENERATIVE BRAIN DISEASE
CEREBROVASCULAR: OTHER SPECIFY
HEMORRHAGE: GASTROINTESTINAL
HEMORRHAGE: INTRAOPERATIVE
HEMORRHAGE: DISSEMINATED INTRAVAS COAGULATION
HEMORRHAGE: POST-OPERATIVE
HEMORRHAGE: RESPIRATORY
HEMORRHAGE: OTHER SPECIFY
MALIG: METASTATIC OTHER SPECIFY
MALIG: PRIMARY OTHER SPECIFY
MALIG: POST-TX LYMPHOPROLIFERATIVE DISORDER
MALIG: LYMPHOMA
MALIG: SKIN
MALIG: OTHER SPECIFY
DIABETES MELLITUS
INTRAOP: NOT HEMORRHAGE - OTHER SPECIFY
PANCREATITIS
RENAL FAILURE
LIVER FAILURE
MULTIPLE ORGAN FAILURE
FLUID/ELECTROLYTE DISORDER
ACID/BASE DISORDER
AMYLOIDOSIS
HEMATOLOGIC OTHER SPECIFY
IMMUNOSUPPRESSIVE DRUG RELATED - HEMATOLOGIC
IMMUNOSUPPRESSIVE DRUG RELATED - NON-HEMATOLOGIC
NON-IMMUNO DRUG RELATED - HEMATOLOGIC
NON-IMMUNO - NON-HEMATOLOGIC, SPECIFY DRUG
MOTOR VEHICLE ACCIDENT
SUICIDE
NON-COMPLIANCE
TRAUMA OTHER SPECIFY
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