Extra Corporeal Membrane Oxygenation
	Intra Aortic Balloon Pump
	Ventilator
	Prostaglandins
	Prostacyclin Infusion
	Prostacyclin Inhalation
	Intravenous Inotropes
	Inhaled NO
	Other mechanism
	Specify:

Patient on Ventricular Assist Device:	NONE LVAD RVAD TAH LVAD+RVAD
VAD Brand 1:
Specify:
Life Support: VAD Brand2
Specify:
Date of VAD implantation:

Angina:

No angina Stable angina - strenuous activity results in angina Stable angina - ordinary physical activity results in angina Stable angina - no rest angina; does have angina with less than ordinary activity Stable angina - angina with any physical activity or at rest Unstable angina Unknown if angina present

Angina:

No Yes, and documented Coronary Artery Disease Yes, with no documented Coronary Artery Disease Yes, but Coronary Artery Disease unknown Status Unknown

If yes, check all that apply:	CABG Valve Replacement/Repair Congenital Left Ventricular Remodeling Other, specify
:	Specify:

Prior Lung Surgery (non-transplant):

YES NO UNK

If yes, check all that apply:	Pneumoreduction Pneumothorax Surgery-Nodule Pneumothorax Decortication Lobectomy Pneumonectomy Left Thoracotomy Right Thoracotomy Other, specify
	Specify:

Prior Thoracic Surgery other than prior transplant:

YES NO UNK