VCA Transplant Recipient Follow Up_Form_redline.xlsx

TRF - VCA - Adult/Pediatric
Fields to be completed by members
Form Section	Field Label	Notes
Recipient Information	Recipient First Name	Display Only - Cascades from Removal Worksheet
Recipient Information	Recipient Last Name	Display Only - Cascades from Removal Worksheet
Recipient Information	Recipient Middle Initial	Display Only - Cascades from Removal Worksheet
Recipient Information	DOB	Display Only - Cascades from Removal Worksheet
Recipient Information	SSN	Display Only - Cascades from Removal Worksheet
Recipient Information	Gender	Display Only - Cascades from Removal Worksheet
Recipient Information	HIC	Display Only - Cascades from TRR
Recipient Information	Transplant Date	Display Only - Cascades from Removal Worksheet
Recipient Information	State of Permanent Residence
Recipient Information	Permanent zip code
Provider Information	Treating Reconstructive Surgeon Name
Provider Information	Treating Reconstructive Surgeon NPI#
Provider Information	Treating Transplant Physician Name
Provider Information	Treating Transplant Physician NPI#
Provider Information	Follow-up Care Provided By:
Donor Information	UNOS Donor ID #	Display Only - Cascades from Removal Worksheet
Donor Information	Donor Type	Display Only - Cascades from Removal Worksheet
Donor Information	OPO	Display Only - Cascades from Removal Worksheet
Patient Status	Date Last Seen, Retransplanted, or Death
Patient Status	Patient Status
Patient Status	Primary Cause of Death
Patient Status	Primary Cause of Death - Other Specify
Patient Status	Has patient been hospitalized since the Last Patient Status Date
Patient Status	Number of Hospitalizations
Socio-Demographic Information	Working for income
Socio-Demographic Information	Working for income - If Yes, indicate the recipient's working status
Socio-Demographic Information	Working for income - If No, Not Working Due To
Socio-Demographic Information - Source of Payment	Grant funding
Socio-Demographic Information - Source of Payment	Institutional funding
Socio-Demographic Information - Source of Payment	Primary Source of Payment
Socio-Demographic Information - Source of Payment	Primary Source of Payment - Foreign Government, Specify
Socio-Demographic Information - Source of Payment	Secondary Source of Payment
Functional Status	Cognitive Development
Functional Status	Motor Development
Functional Status	Psychosocial consult performed
Functional Status: Pre-transplant - SF-36 score - Physical Health	Physical Functioning (PF) score
Functional Status: Pre-transplant - SF-36 score - Physical Health	Role-Physical (RP) score
Functional Status: Pre-transplant - SF-36 score - Physical Health	Bodily Pain (BP) score
Functional Status: Pre-transplant - SF-36 score - Physical Health	General Health (GH) score
Functional Status: Pre-transplant - SF-36 score - Mental Health	Vitality (VT) score
Functional Status: Pre-transplant - SF-36 score - Mental Health	Social Functioning (SF) score
Functional Status: Pre-transplant - SF-36 score - Mental Health	Role-Emotional (RE) score
Functional Status: Pre-transplant - SF-36 score - Mental Health	Mental Heath (MH) score
Functional Status: Pre-transplant - SF-12 score - Physical Health	Physical Functioning (PF) score
Functional Status: Pre-transplant - SF-12 score - Physical Health	Role-Physical (RP) score
Functional Status: Pre-transplant - SF-12 score - Physical Health	Bodily Pain (BP) score
Functional Status: Pre-transplant - SF-12 score - Physical Health	General Health (GH) score
Functional Status: Pre-transplant - SF-12 score - Physical Health	Physical Component Summary (PCS) score
Functional Status: Pre-transplant - SF-12 score - Mental Health	Vitality (VT) score
Functional Status: Pre-transplant - SF-12 score - Mental Health	Social Functioning (SF) score
Functional Status: Pre-transplant - SF-12 score - Mental Health	Role-Emotional (RE) score
Functional Status: Pre-transplant - SF-12 score - Mental Health	Mental Heath (MH) score
Functional Status: Pre-transplant - SF-12 score - Mental Health	Mental Component Summary (MCS) score
Functional Status - Upper Limb	DASH Score
Functional Status - Upper Limb	Carroll Test Score - Left
Functional Status - Upper Limb	Carroll Test Score - Right
Functional Status - Upper Limb	Sensibility Test - Semmes Weinstein - Left
Functional Status - Upper Limb	Sensibility Test - Semmes Weinstein - Right
Functional Status - Upper limb	Hot and cold sensation
Functional Status - Upper limb	Two-point discrimination test
Functional Status - Upper limb	Grip strength and pinch test
Functional Status - Upper limb	Is the patient able to make a fist?
Functional Status - Upper limb	Can the patient comb their hair?
Functional Status - Upper limb	Can the patient open a door?
Functional Status - Upper limb	Can the patient write on a piece of paper?
Functional Status - Upper limb	Can the patient hold a cup?
Functional Status - Head and Neck	Smile restoration
Functional Status - Head and Neck	Ability to open and close eyelids
Functional Status - Craniofacial	Olfactory function restored
Functional Status - Craniofacial - Sensory Testing	2 point discrimination (mm) Two-point discrimination test
Functional Status - Craniofacial - Sensory Testing - Hot/cold testing	Can feel heat Hot and cold sensation
Functional Status - Craniofacial - Sensory Testing - Hot/cold testing	Can feel cold
Functional Status - Craniofacial - Motor function	Oral competence
Functional Status - Craniofacial - Motor function	Corneal protection
Functional Status - Craniofacial	Functional occlusion restored
Functional Status - Craniofacial	Decannulation (if the patient had a tracheostomy)
Functional Status - Craniofacial	Feeding Tube Removed (if the patient had a feeding tube to start with)
Functional Status - Craniofacial - Speech Intelligibility Tests	Speaking rate
Functional Status - Craniofacial - Speech Intelligibility Tests	Percent Intelligibility
Functional Status - Uterus	Number of embryo transfers during this follow-up period
Functional Status - Uterus	{For each transfer} Number of embryo transfers// Embryo transfer date
Functional Status - Uterus	{For each transfer} Number of embryo transfers// Reason if no embryo transfer date	Date or reason is reported, not both
Functional Status - Uterus	Number of pregnancies post-transplant of uterus during this follow-up period (which may or may not have resulted in a live birth)
Functional Status - Uterus	{For each pregnancy} Date of positive pregnancy test result post-transplant
Functional Status - Uterus	{For each pregnancy} Date of positive pregnancy test result post-transplant//Reason if no date of positive pregnancy test result	Date or reason is reported, not both
Functional Status - Uterus	{For each pregnancy} Date embryonic heartbeat first detected by ultrasound
Functional Status - Uterus	{For each pregnancy} Date embryonic heartbeat first detected by ultrasound// Reason if no date of embryonic heartbeat first detected by ultrasound	Date or reason is reported, not both
Functional Status - Uterus	{For each pregnancy} Estimated delivery date
Functional Status - Uterus	{For each pregnancy} Estimated delivery date// Reason if no estimated delivery date	Date or reason is reported, not both
Functional Status - Uterus	{For each pregnancy} Pregnancy complications
Functional Status - Uterus	{For each pregnancy} Pregnancy complications// If yes, specify
Functional Status - Uterus	{For each pregnancy} Did pregnancy result in a miscarriage?
Functional Status - Uterus	{For each pregnancy} Did pregnancy result in a miscarriage?// If yes, date of miscarriage
Functional Status - Uterus	{For each pregnancy} Date of admission to Transplant Center for delivery
Functional Status - Uterus	{For each pregnancy} Date of admission to Transplant Center for delivery// Reason if no date of admission to Transplant Center for delivery	Date or reason is reported, not both
Functional Status - Uterus	{For each pregnancy} Delivery type
Functional Status - Uterus	{For each pregnancy} Delivery type// Delivery date
Functional Status - Uterus	{For each pregnancy} Maternal complications at delivery
Functional Status - Uterus	{For each pregnancy} Maternal complications at delivery// If yes, specify
Functional Status - Uterus	{For each pregnancy} Blood transfusions required following delivery
Functional Status - Uterus	{For each pregnancy} Date of discharge from Transplant Center post-delivery
Functional Status - Uterus	{For each pregnancy} Date of discharge from Transplant Center post-delivery// Reason if no date of discharge from Transplant Center post-delivery	Date or reason is reported, not both
Functional Status - Uterus	{For each pregnancy} Post-delivery complications
Functional Status - Uterus	{For each pregnancy} Post-delivery complications// If yes, specify
Functional Status - Uterus	{For each pregnancy} Subsequent surgeries since delivery
Functional Status - Uterus	{For each surgical procedure} Subsequent surgeries since delivery// If yes, enter each surgical procedure
Functional Status - Uterus	{For each surgical procedure} Subsequent surgeries since delivery// Surgical date
Functional Status - Uterus	Readmitted to the hospital
Functional Status - Uterus	{For each readmission} Readmitted to the hospital// If yes, reason for readmission
Functional Status - Uterus	{For each readmission} Readmitted to the hospital// If yes, readmission date
Functional Status - Uterus	Hysterectomy performed following successful delivery or due to complication
Functional Status - Uterus	Hysterectomy performed following successful delivery or due to complication // Hysterectomy date
Functional Status - Uterus	Hysterectomy performed following successful delivery or due to complication // Other specify
Functional Status - Uterus	Hysterectomy performed following successful delivery or due to complication // If yes, then specify reason
Functional Status - Uterus	Hysterectomy performed following successful delivery or due to complication // If yes and reason is other // Other specify
Functional Status - Uterus	Surgical, medical, or psychiatric complications after hysterectomy
Functional Status - Uterus	{For each complication} Surgical, medical, or psychiatric complications after hysterectomy// If yes, specify each complication
Functional Status - Uterus	{For each complication} Surgical, medical, or psychiatric complications after hysterectomy// If yes, date
Functional Status - Uterus	New onset diagnosed psychiatric condition(s)
Functional Status - Uterus	New onset diagnosed psychiatric condition(s)// If yes, specify
Functional Status - Uterus	Visual changes noted on cervical examination
Functional Status - Uterus	Visual changes noted on cervical examination// If yes, specify
Clinical Information	Height (inches)
Clinical Information	Weight (lbs.)
Clinical Information	BMI (Body Mass Index)	Display Only - Calculated
Clinical Information - Noncompliance	Immunosuppression
Clinical Information - Noncompliance	Rehabilitation
Clinical Information - Noncompliance	Level of Activity
Clinical Information - Noncompliance	Other
Clinical Information - Noncompliance	Other - Other Specify
Clinical Information	Graft Status
Clinical Information	Date of Graft Failure
Clinical Information	{If Graft Status = Planned Removal} Date of Removal	Only applicable for Uterus
Clinical Information - Causes of Graft Failure	Acute Rejection
Clinical Information - Causes of Graft Failure	Acute Rejection - Banff score
Clinical Information - Causes of Graft Failure	Acute Rejection - Visual skin changes	Not applicable for Uterus
Clinical Information - Causes of Graft Failure	Chronic Rejection
Clinical Information - Causes of Graft Failure	Chronic Rejection - Visual skin changes
Clinical Information - Causes of Graft Failure	Ischemia
Clinical Information - Causes of Graft Failure	Vascular complications
Clinical Information - Causes of Graft Failure	Sepsis / Infection
Clinical Information - Causes of Graft Failure	Trauma
Clinical Information - Causes of Graft Failure	Patient requested removal
Clinical Information - Causes of Graft Failure	Non-compliance: immunosuppression
Clinical Information - Causes of Graft Failure	Non-compliance: rehabilitation
Clinical Information - Causes of Graft Failure	Non-compliance: level of activity
Clinical Information - Causes of Graft Failure	Non-adherence
Clinical Information - Causes of Graft Failure	Other
Clinical Information - Causes of Graft Failure	Other - Other Specify
Clinical Information - Most Recent Lab Data	Serum Creatinine (mg/dL)
Clinical Information - Most Recent Lab Data	Hemoglobin A1c (%)
Clinical Information - Most Recent Lab Data	Donor Specific Antibodies (DSA)
Clinical Information - Post Transplant	Did patient have any acute rejection episodes during the follow-up period
Clinical Information - Post Transplant	Did patient have any acute rejection episodes during the follow-up period - Number of episodes
Clinical Information	{For each episode} Date of acute rejection diagnosis
Clinical Information	{For each episode} Acute rejection was treated
Clinical Information	{For each episode} Visual skin changes
Clinical Information	{For each episode} Biopsy was done to confirm acute rejection
Clinical Information	{For each episode} Banff Score
Clinical Information - Complications	New onset diabetes
Clinical Information - Complications	Metabolic Complications
Clinical Information - Complications	Infectious Complications
Clinical Information - Complications	Other Complications
Clinical Information - Complications	Other Complications - Other Specify
Clinical Information - Upper limb	Subsequent surgeries required
Clinical Information - Upper limb	{For each surgical procedure} Subsequent surgeries required// If yes, enter each surgical procedure
Clinical Information - Upper limb	{For each surgical procedure} Subsequent surgeries required// Surgical date
Clinical Information	Post Transplant Malignancy
Clinical Information - Post-transplant Malignancy	Donor Related
Clinical Information - Post-transplant Malignancy - Donor Related	Diagnosis date:
Clinical Information - Post-transplant Malignancy - Donor Related	Tumor type
Clinical Information - Post-transplant Malignancy	Recurrence of Pre-Tx Tumor
Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy	Date of recurrence
Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy	Type of pre-existing tumor
Clinical Information - Post-transplant Malignancy - Recurrence of Pretransplant Malignancy	Type of pre-existing tumor - Other, Specify
Clinical Information - Post-transplant Malignancy	De Novo Solid Tumor
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Diagnosis date
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Skin: //squamous cell:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Skin: //basal cell:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Skin: //melanoma:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Kaposi's sarcoma: cutaneous:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Kaposi's sarcoma: visceral:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Brain:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: Brain: //Other specify:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Renal carcinoma - specify site(s):
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Carcinoma of vulva, perineum or penis, scrotum:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Carcinoma of the uterus:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Ovarian:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Testicular:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Esophagus:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Stomach:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Small intestine:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Pancreas:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Larynx:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Tongue, throat:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Thyroid:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Bladder:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Breast:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Prostate:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Colo-rectal:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Primary hepatic tumor:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Metastatic liver tumor:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Lung:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types://Leukemia:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Sarcomas:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Other cancers:
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Other Cancers: //Site(s):
Clinical Information - Post-transplant Malignancy - Post Transplant De Novo Solid Tumor	Tumor Types: //Primary unknown:
Clinical Information - Post-transplant Malignancy	De Novo Lymphoproliferative disease and Lymphoma
Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma	PTLD: //Diagnosis date:
Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma	PTLD: //Pathology:
Clinical Information - Post-transplant Malignancy - Post Transplant Lymphoproliferative Disease and Lymphoma	PTLD: Pathology: //Other Specify:
Treatment	Antiviral
Treatment	Antibiotic
Treatment	Antifungal
Topical Immunosuppressive Medications	Immunosuppression medications	Not applicable for Uterus
Topical Immunosuppressive Medications	Immunosuppression medications - Other Specify	Not applicable for Uterus
Topical Immunosuppressive Medications	Previous maintenance indication	Not applicable for Uterus
Topical Immunosuppressive Medications	Current maintenance indication	Not applicable for Uterus
Topical Immunosuppressive Medications	Anti-rejection indication	Not applicable for Uterus
Non-Topical Immunosuppressive Medications	Immunosuppression medications
Non-Topical Immunosuppressive Medications	Immunosuppression medications - Other Specify
Non-Topical Immunosuppressive Medications	Previous maintenance indication
Non-Topical Immunosuppressive Medications	Current maintenance indication
Non-Topical Immunosuppressive Medications	Anti-rejection indication
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