Reference Guide
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Identifier: 01CN012
Center: 01CN01-Royal Victoria Hospital

MEDICAL CONDITION
Patient Medical Condition/Current Status:*
Patient on Life Support:*
Examples: ECMO, IABP, Ventilator, PGE(Prostaglandins), IV Inotropes, Inhaled NO.
Extra Corporeal Membrane Oxygenation:*
Intra Aortic Balloon Pump:*
Ventilator:*
PGE (Prostaglandins):*
IV Inotropes (Intravenous Inotropes):*
Inotropic Agent (check all that apply):*
  Specify:*
Inhaled NO:*
Home O2:*
Ross/NYHA Class:*
ISHLT/AHA Disease Staging:*
PEDIMACS Profile:*
Pedimacs Profile of Advanced Heart Failure
Modifier 'A' - Arrythmia:*
Modifier 'TCS' - Temporary Circulatory Support:*
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):*
  CV Specify:*
  Genetic Syndrome Specify:*
  Metabolic Syndrome Specify:*
  Neuromuscular Disease Specify:*
  Cerebrovascularular Disease Specify:*
  Pulmonary Disease Specify:*
  Rheumatologic Condition Specify:*
  Specify:*
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:*
Prior Cardiac Operation (check all that apply):*
  Specify:*
Peripheral Edema:*

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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