Transplant Candidate Registration Form (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Submitting this paper form does not add your patient to the waiting list. Page 1 of 2 Provider Information Organ Registered: Kidney Date placed on list: Provider Number UNOS Center Code Center Name Candidate Information Name: Previous Surname: Last First MI DOB: SSN: HIC: Gender: Male Female State of Permanent Residence: Permanent Zip Code: Waiting Zip Code: Employment Status (Select one) (Working = Employed, Home, School) Ethnicity Hispanic/Latino Non-Hispanic/Non-Latino Working Full Time Race Working Part Time By Choice White Native Hawaiian or Working Part Time Due to Disease Black or African American other Pacific Islander Working Part Time, Reason Unknown American Indian or Alaskan Mid-East or Arabian Not Working By Choice Native Indian Sub-Continent Not Working Due to Disease Asian Not Working, Unable to Find Employment Not Working, Reason Unknown Citizenship (Select one) Retired U.S. Citizen Resident Alien Employment Status Unknown Non-Resident Alien Patient Less Than Five Years Old Home country: Previous Transplants Highest Education Level (Select one) Yes No None Associate/Bachelor If Yes, give the number of previous transplants for each organ type and Grade School (0-8) Degree latest transplant date. High School (9-12) Post-College Graduate Number Date Attended College/Technical Degree Kidney School Unknown Liver Pancreas (whole) Medical Condition (Select one) Pancreas (islet cells) Patient in Intensive Care Unit Heart Hospitalized, but not in Intensive Care Unit Lung Not hospitalized Intestine Patient on Life Support Bone Marrow (Please provide for all patients regardless of medical status) Source of Payment Yes No (Check Yes, No or Unknown for each secondary source of payment) (Check applicable) Primary (Largest %, Select one) Secondary ECMO IABP PGE IV Inotropes Medicare Y NU Ventilator Other mechanism Medicaid Y NU Specify: US/State Government Agency Y NU VAD Brands Private Insurance Y NU Cardio West Thoratec HMO/PPO Y NU Abiomed Other VAD, specify: Self Y NU Novacor Donation Y NU Heartmate Free Care Y NU Functional Status (Select one) (How does patient perform daily activities?) Dept. of Veterans Affairs Pending No activity limitations. (NYHA Class I or Class II) Foreign Govt., Specify: Performs activities of daily living with some assistance. (NYHA Class III) Performs activities of daily living with total assistance. (NYHA Class IV) N/A Patient hospitalized Unknown UNOS/PHS/HCFA 3/29/01 Transplant Candidate Registration Form FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Name: Page 2 of 2 Clinical Information Height ft. in. OR cm Weight lbs. OR kg ABO Blood Group: Rh: Primary Diagnosis (Use codes) If other, specify: General Medical Factors Diabetes No Diabetes Insulin Dependent Diabetes Non-Insulin Dependent Diabetes Diabetes, Dependency Unknown Unknown Dialysis No Dialysis Hemodialysis Peritoneal Dialysis Peptic Ulcer Disease No Yes, Drug Treated Yes, Not Drug Treated Yes, Drug Treatment Unknown Unknown Angina/Coronary Artery Disease No Angina, Unstable Angina, Stable Angina, Stability Unknown Unknown Drug Treated Systemic Hypertension Y NU Symptomatic Cerebrovascular Disease Y NU Symptomatic Peripheral Vascular Disease Y NU Drug Treated COPD Y NU Pulmonary Embolism (within last 6 months) Y NU Any Previous Transfusions Y NU Any Previous Malignancy Y NU (Exclude non-melanoma skin cancer) PRA > 10% (with DTT or DTE testing) Y NU Most recent absolute Creatinine mg/dl Total Serum Albumin g/dl Kidney Medical Factors Exhausted vascular access Y NU Exhausted peritoneal access Y NU Age of diabetes onset yrs Creatinine clearance ml/min Creatinine clearance method: Isotope Calculated Measured Standard UNOS/PHS/HCFA 1/28/00 Person completing form: Date completed: Kidney Transplant Recipient Registration Form (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 2 Provider Information Provider Number Center Code Transplant Center Name Surgeon Name UPIN Number Recipient Information Name: Transplant Date: Last First MI DOB: SSN: HIC: Gender: Male Female Patient Status Donor Information Donor Type: Primary Diagnosis Specify: (Use code) UNOS Donor ID Donor Name: Last First Patient Status Source of Payment (Check Yes, No or Unk for each secondary source) Date: of Report or Death Primary (Largest %, Select one) Secondary Living Medicare Y NU Dead Cause of Death: Medicaid Y NU (Use code) Specify: US/State Government Agency Y NU Retransplanted prior to hospital discharge Private Insurance Y NU HMO/PPO Y NU Transplant Hospitalization Self Y NU Date of discharge from transplant center: Donation Y NU Date of admission to transplant center: Free Care Y NU Was patient transferred from another hospital prior to transplant? Dept. of Veterans Affairs Foreign Gov’t. Specify: Yes No If Yes, date of admission to transferring hospital: Medical Condition at Time of Transplant (Select one) Pretransplant Clinical Information Patient in Intensive Care Unit Previous Kidney Transplants Yes No Hospitalized, but not in Intensive Care Unit If Yes, number of previous kidney transplants: Not hospitalized Previous Tx Transplant Date Graft Failure Date Patient on Life Support Yes No Most recent (Please provide for all patients regardless of medical status) 2nd most recent 3rd most recent Functional Status (How does the patient perform activities of daily living? Select one) Pretransplant Dialysis No activity limitations. (NYHA Class I or Class II) None Hemodialysis Peritoneal dialysis Performs activities of daily living with some assistance. If Yes, date first dialyzed: (NYHA Class III) Average daily insulin: units Performs activities of daily living with total assistance. Serum Creatinine at time of transplant: mg/dl (NYHA Class IV) Creatinine clearance: ml/min N/A Patient hospitalized Creatinine clearance method: Unknown Isotope Calculated Measured standard Employment Status (Select one) (Working = Employed, Home, School) Pretransplant Serology Working Full Time HIV Screening P N U ND I C Confirmation P N U ND I C Working Part Time By Choice CMV IgG P N U ND I C Working Part Time Due to Disease IgM P N U ND I C Working Part Time, Reason Unknown DNA P N U ND I C Not Working By Choice Hepatitis B Core Antibody P N U ND I C Surface Antigen P N U ND I C Not Working Due to Disease HBV DNA P N U ND I C Not Working, Unable to Find Employment Hepatitis C Antibody Screen P N U ND I C Not Working, Reason Unknown RIBA Test P N U ND I C Retired HCV RNA P N U ND I C Epstein Barr Virus IgG P N U ND I C Employment Status Unknown IgM P N U ND I C Patient Less Than Five Years Old DNA P N U ND I C UNOS/PHS/HCFA 5/18/01 Kidney Transplant Recipient Registration Form FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Name: Page 2 of 2 Biopsy of Donor Kidney at Transplant Center Most recent Serum Creatinine prior to discharge: mg/dl No biopsy done Frozen Left Kidney Did kidney produce > 40 ml of urine in the Y N Permanent Left Kidney first 24 hours? Frozen Right Kidney Did patient need dialysis within first week? Y N Permanent Right Kidney Did Creatinine decline by 25% or more in first Y N Frozen En-bloc Kidney 24 hours on 2 separate serum samples taken Permanent En-bloc Kidney within the first 24 hours? Kidney Results: Rejection Information Glomerulosclerosis % Fibrosis Arteriolosclerosis Patient treated for rejection? Y N 0-5 None None If Yes, biopsy done? Y N 6-10 Mild Mild If Yes, rejection confirmed? Y N 11-15 Moderate Moderate 16-20 Large Large BANFF Level: Y N > 20 Stages: 1A 1B 2 3 Pretransplant Blood Transfusions: Height ft. in. OR cm 0 1-5 6-10 >10 Unk Weight lbs. OR kg Date of last transfusion: Donor specific transfusions? Yes No Unk Treatment Number of previous pregnancies: Immunosuppressive Information 0 1 2 3 4 5 >5 Unk Are any medications given currently for Y N maintenance or anti-rejection: Any known malignancies since listing: Yes No Unk Did the patient participate in any clinical Y N Transplant Clinical Information research protocol for immunosuppressive medications: If Yes, specify: Multiple Organ Recipient: Other Therapy Procedure Type: Photopheresis Y N Plasmapheresis Y N Preservation Information Total Cold Ischemic Time: hrs Total Lymphoid Irradiation (TLI) Y N Anastomotic Time: min Biologicals/Vaccines Warm Ischemic Time: min Total Pump Time: hrs min Cytogam (CMV) Y N Gamimune N 10% Y N Number of blood transfusions at time of transplant: Gammagard SD Y N Post Transplant Clinical Information Acyclovir (Zovirax) Y N Ganciclovir (Cytovene) Y N Graft Status: Functioning Failed HBIG (Hepatitis B Immume Globulin) Y N Resumed maintenance dialysis: Yes No Flu Vaccine (Influenza virus) Y N If Yes, date resumed: Dialysis center provider #: Other: Dialysis center name: Other: If failed, date of graft failure: Cause of graft failure (Check Yes, No or Unknown for each contributory cause of graft failure) Primary (Check one) Contributory Hyperacute rejection Acute rejection Y NU Primary failure Graft thrombosis Y NU Infection Y NU Surgical complications Y NU Urological complications Y NU Recurrent disease Y NU Other: Other: UNOS/PHS/HCFA 3/29/01 Person completing form: Date completed: Immunosuppression Treatment (Please print or type all information) FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2002 Page 1 of 1 Recipient Information Name: Last First MI Provider Number Center Code Tx Center Name Donor Information UNOS