Reference Guide
Patient Follow-Ups
 
 
Identifier: 7547687
Center: 01CN01-Royal Victoria Hospital

1 Year Annual Follow Up
Note: If the patient has been transplanted or had a mechanical support device implanted during the follow-up period, please report the patient’s status and values just prior to the transplant or implant.
FOLLOW UP INFORMATION
Patient Status at Time of Follow-Up:*
Date: Last Seen or Death:* mm/dd/yyyy

PATIENT HISTORY
In The Last Year, Has Patient Care Been Transferred To A Different Medical Center:*
Date of Transfer:* mm/dd/yyyy
In The Last Year, Has Patient Been Listed for Transplant:*
Date Listed: mm/dd/yyyy
Listing Reported to PHTS:*
Ross/NYHA Class:*
ISHLT/AHA Disease Staging:*
In The Past Year Was The Patient Transplanted:*
mm/dd/yyyy
Transplant Reported to PHTS: *
Transplant Reported to the ISHLT Transplant Registry:*
Has The Patient Been Hospitalized Since The Last Patient Status Date/Report:*
Did Patient Require ECMO Support:*
ECMO Date:* mm/dd/yyyy
ECMO Outcome:*
ECMO Date of Outcome:* mm/dd/yyyy
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:

PATIENT STATUS
Patient Status Date:* mm/dd/yyyy
Functional Status:*
Mobility (age appropriate):*
Academic Progress:
Academic Activity Level:*
Cognitive Development:*
Motor Development:*

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

HEMODYNAMICS
mmHg
Diastolic BP: mmHg
bpm

ECHO
Ejection Fraction:* %  
LVEDD:* cm  
cm  
cm  
m/s  
mmHg  
mmHg  
Ratio

MEDICAL HISTORY
Experienced Recovery (EF>40%):*
Become Dependent on Continuous Inotropes:*
Which Inotropes (check all that apply):*
  Specify:*
Resuscitated Since Last Followup:*
Co-morbidities (check all that apply):*
  CV Specify:*
  Genetic Syndrome Specify:*
  Metabolic Syndrome Specify:*
  *
  Cerebrovascularular Disease Specify:*
  Pulmonary Disease Specify:*
  Rheumatologic Condition Specify:*
  Specify:*

LABORATORY
Report values closest to the time of presentation
Creatinine:* µmol/l  
µmol/l
g/l
mmol/L
mmol/L
mmol/L
U/I
IU/I
BNP:* pg/ml  
nt-pro BNP:* pg/ml  
*109/L
Hemoglobin:* g/l  
*109/L
Ratio
*109/L

EXERCISE FUNCTION
Exercise Test:*
Peak Oxygen Uptake V02:* mL/kg/min  
Resting HR:* bpm  
Peak HR:* bpm  
Peak Oxygen Uptake:* %  
Peak RER:* Ratio  
Six Minute Walk:*
Six Minute Walk Distance:* meters  

TESTING
Endomyocardial Biopsy:*

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:*

Nutrition:*
 
ISHLT PEDIATRIC HEART FAILURE REGISTRY
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