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DEMOGRAPHICS
CLINICAL ENROLLMENT
ENROLLMENT TESTING
DEATH
Identifier:
Center:
DEATH
Date of Death:
*
mm/dd/yyyy
Location of Death:
*
In Hospital
Out of Hospital
Unknown
Primary Cause of Death:
*
Cancer
Circulatory: Arrhythmia
Circulatory: Congestive Heart Failure
Circulatory: Endstage Cardiomyopathy
Circulatory: Other
Circulatory: Sudden Unexplained Death
Circulatoryulatory: Right Heart Failure
Fluid/Electrolyte Disorder
Hepatic Dysfunction
Major Bleeding
Major Infection
Multisystem Heart Failure
Neurologic Disorder, Specify
Neurologic Event
Renal Dysfunction
Respiratory: Pulmonary Embolism
Respiratory: Pulmonary, Other
Respiratory: Respiratory Failure
Suicide
Trauma/Accident, Specify
Withdrawal of Support, Specify
Other, Specify
Unknown
Specify:
*
Secondary Cause of Death (check all that apply):
Cancer
Circulatory: Arrhythmia
Circulatory: Congestive Heart Failure
Circulatory: Endstage Cardiomyopathy
Circulatory: Other
Circulatory: Sudden Unexplained Death
Circulatoryulatory: Right Heart Failure
Fluid/Electrolyte Disorder
Hepatic Dysfunction
Major Bleeding
Major Infection
Multisystem Heart Failure
Neurologic Disorder, Specify
Neurologic Event
Renal Dysfunction
Respiratory: Pulmonary Embolism
Respiratory: Pulmonary, Other
Respiratory: Respiratory Failure
Suicide
Trauma/Accident, Specify
Withdrawal of Support, Specify
Other, Specify
Unknown
Circulatory Other:
Neurologic Disorder Specify:
Respiratory Pulmonary Other:
Trauma/Accident Specify:
Withdrawal of Support Specify:
Specify:
Autopsy:
Yes
No
Unknown
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ISHLT PEDIATRIC HEART FAILURE REGISTRY
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