1144 E. Home Road, Suite B • Springfield, Ohio 45503-2797
Phone (614) 504-5705 • Fax (614) 504-5707
www.osotc.org
HEART CANDIDATE SUMMARY
OSOTC Patient Number:
Patient Demographics
Initials:
Gender:
Birth Date:
M
F
ABO:
A
Institutional Approval Date:
B
AB
O
City/State of Residence:
Race:
Marital Status:
County if Ohio:
Height:
Weight:
BMI:
Transplant#:
Patient Status
Medical Diagnosis:
1A
UNOS Status:
1B
2
7
NYHA Functional Class:
1A Status Justification:
1) Mechanical circulatory support: Yes
No
Date:
Device:
Complications:
2) Pulmonary artery catheter:
Yes
No
3) Inotrope support:
Yes
No
Dose:
4) Exception:
Yes
No
Explain:
1) VAD:
Yes
No
Date:
2) Inotrope support:
Yes
No
Dose:
1B Status Justification:
PATIENT CARE LOCATION:
Outpatient
Device:
Inpatient not in ICU or special care unit
MEDICAL HISTORY (Co-morbidities, AICD, infection, etc.):
Inpatient in ICU or special care unit
ICD:
CRT:
SURGICAL HISTORY (Previous transplant surgery, CABG, valve repair, stent, etc.):
Right Heart Catheterization
Date
HR
BP
RA
RV
PA (S/D/M)
TR
RV
Comments
PCWP
Echocardiogram Results
EF
EDD
MR
Cardiopulmonary Exercise Test
Peak VO2:
%Predicted for Age:
VE/VCO2:
TPG
PVR
CO/CI
Drug?
Date:
Not Done
Date:
Not Done
RER:
(v15.0528)
Heart Candidate Summary
Page 2 of 2
Pulmonary Function Test
FVC
%FVC
Date:
FEV1
%FEV1
%DLCO
pH
pO2
Not Done
pCO2
HCO3
FiO2
Sat
Cancer Screening Results
MALIGNANCY HISTORY:
Laboratory Results
WBC:
Hgb:
HCT:
Plts:
PT:
INR:
Date:
Sodium:
Potassium:
BUN:
Creatinine:
Creat.Clear:
Renal Failure: Yes
No
T.Bili:
Alk Phos:
AST:
ALT:
T.Protein:
Albumin:
Not Done
TSH:
Cholesterol:
Triglycerides:
HDL:
History of Substance Use
Tobacco Use:
N/A
Does patient meet 6 month tobacco abstinence requirement? Yes
N/A
Drug Use:
Type:
Quit:
ETOH Use:
Alcohol Use Disorder: Yes
Quit:
No
No
If no, please provide justification for listing under the medically urgent criteria (1A or unstable
1B):
Substance Use Disorder: Yes
Type:
Quit:
N/A
No
PSYCHOSOCIAL EVALUATION/QUALITY OF LIFE
(Support system, informed consent, attitude about transplant, aftercare, complications, chemical dependency history, etc.):
Performed by:
Social Worker
Psychiatrist
Other
Insurance:
(v15.0528)