Reference Guide
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Identifier:
Center:
 

MEDICAL CONDITION
Patient Medical Condition/Current Status:*
Patient on Life Support:*
Examples: ECMO, IABP, Ventilator, PGE(Prostaglandins), IV Inotropes, Inhaled NO.
Home O2:*
Ross/NYHA Class:*
Ross/NYHA Classifications
ISHLT/AHA Disease Staging:*
PEDIMACS Profile:*
Pedimacs Profile of Advanced Heart Failure
Modifier 'FF' - Frequent Flyer:*

PATIENT STATUS
Functional Status:*
Mobility (age appropriate):*
Academic Activity Level:*
Cognitive Development:*
Motor Development:*

CLINICAL INFORMATION
Date of Measurement:* mm/dd/yyyy
Height:* cm  
Weight:* kg  

MEDICAL HISTORY
Co-morbidities (check all that apply):*
Prior Ablation:*
History of Renal Replacement Therapy:*
History of Atrial Arrhythmia(s):*
History of Ventricular Arrhythmia(s):*
History of Pacemaker:*
Implantable Defibrillator:*
Cardiac Resynchronization Therapy:*
Prior Congenital Cardiac Surgery:*
Peripheral Edema:*

MEDICATIONS
ACEI:*
Beta Blocker:*
Aldosterone Antagonist:*
Antiarrhythmic:*
Calcium Channel Blockers:*
Phosphodiesterase Inhibitors:*
Angiotensin Receptor Blocker Drug:*
Digoxin:*
Anticoagulants (check all that apply):*
Diuretics:*
Other Medications:*
Medications (check all that apply):*
 
ISHLT PEDIATRIC HEART FAILURE REGISTRY
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