<p> 9200 Memorial Drive • Plain City, Ohio 43064 Phone (614) 504-5705 • Fax (614) 504-5707 www.osotc.org</p><p>PEDIATRIC HEART CANDIDATE SUMMARY </p><p>OSOTC Patient Number: </p><p>Patient Demographics Initials: Birth Date: Institutional Approval Date: </p><p>Gender: M F ABO: A B AB O Race: Marital Status: </p><p>City/State of Residence: County if Ohio: </p><p>Height: Weight: BMI: Transplant#: </p><p>Patient Status Medical Diagnosis: NYHA Functional Class: </p><p>Mechanical Circulation Support Device: Yes No Device: Date: </p><p>UNOS Status: 1A 1B 2 7 Patient care location: Intubated: Yes No Outpatient On dialysis: Yes No Inpatient not in ICU or special care unit Pulmonary artery catheter in place: Yes No Inpatient in ICU or special care unit MEDICAL HISTORY (Please indicate co-morbidities, AICD, infection, etc.):</p><p>SURGICAL HISTORY (Please indicate previous transplant surgery, CABG, valve repair, stent, etc.):</p><p>Right Heart Catheterization Date: Not Done Date HR BP RA RV PA (S/D/M) PCWP TPG PVR CO/CI Drug?</p><p>Left Heart Catheterization Date: Not Done Date HR BP RA RV PA (S/D/M) PCWP TPG PVR CO/CI Drug?</p><p>Echocardiogram Results Date: Not Done </p><p>Electrocardiogram Results Date: Not Done </p><p>Cardiopulmonary Exercise Test Date: Not Done Peak VO2: %Predicted for Age: VE/VCO2: RER: </p><p>Pertinent Chest X-Ray Results Date: Not Done </p><p>Pediatric Heart Candidate Summary Page 2 of 2</p><p>Pulmonary Function Test Date: Not Done FVC %FVC FEV1 %FEV1 %DLCO pH pO2 pCO2 HCO3 FiO2 Sat</p><p>Laboratory Results Date: Not Done WBC: BUN: ALT: Hep A: Hgb: Creatinine: T.Protein: Hep B: HCT: Creat.Clear: Albumin: Hep C: Plts: Renal Failure: (Y/N) Cholesterol: CMV+: PT: T.Bili: Triglycerides: EBV+: INR: Alk Phos: HDL: Rh: Sodium: AST: TSH: % PRA: Potassium: </p><p>Current Medications List all medications: Administered: Enteral IV Ventilator Other Enteral IV Ventilator Other</p><p>Enteral IV Ventilator Other</p><p>Enteral IV Ventilator Other Enteral IV Ventilator Other Enteral IV Ventilator Other Enteral IV Ventilator Other Enteral IV Ventilator Other Enteral IV Ventilator Other Enteral IV Ventilator Other Enteral IV Ventilator Other</p><p>Enteral IV Ventilator Other</p><p>Enteral IV Ventilator Other Enteral IV Ventilator Other Enteral IV Ventilator Other</p><p>History of Substance Use Tobacco Use: N/A ETOH Use: N/A Drug Use: N/A Type: Abuse: Yes No Abuse: Yes No Quit: Dependence: Yes No Dependence: Yes No Quit: Type: Quit: </p><p>PSYCHOSOCIAL EVALUATION/QUALITY OF LIFE (Support system, informed consent, attitude about transplant, aftercare, complications, chemical dependency history, etc.):</p><p>Performed by: Social Worker Psychiatrist Other: Insurance: Ohio Medicaid Billing Number (if applicable): </p>