Reference Guide
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Identifier:
Center:
 

HOSPITALIZATION
Date of Admission:* mm/dd/yyyy
Date of Discharge:* mm/dd/yyyy
Primary Reason for Hospitalization:*
Interventions Initiated Upon Hospital Admission (check all that apply):*
All Subsequent Interventions During Hospitalization (check all that apply):*

TESTING
Endomyocardial Biopsy:*

PATIENT HISTORY
Listed for Transplant:*
Transplanted:*
Did Patient Receive a MCSD:*
Has there been a change in function on Echo or MRI since last reported:*

MEDICATIONS AT THE TIME OF HOSPITAL DISCHARGE
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):*

Nutrition:*
 
ISHLT PEDIATRIC HEART FAILURE REGISTRY
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