Reference Guide
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Identifier: 01CN011
Center: 01CN01-Royal Victoria Hospital

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

TESTING
Endomyocardial Biopsy:*

PATIENT HISTORY
Listed for Transplant:*
Date Listed:* mm/dd/yyyy
Listing Reported to PHTS:*
Transplanted:*
mm/dd/yyyy
Transplant Reported to PHTS: *
Transplant Reported to the ISHLT Transplant Registry:*
Did Patient Receive a MCSD:*
Date:* mm/dd/yyyy
Type:*
Intended Support Strategy (check all that apply):*
  Specify:*
Reported to VAD registry:*
VAD Registry:*
Specify:*

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