1144 E. Home Road, Suite B • Springfield, Ohio 45503-2797
Phone (614) 504-5705 • Fax (614) 504-5707
www.osotc.org
LIVER CANDIDATE SUMMARY
Kidney
Pancreas
Other:
OSOTC Patient Number:
PATIENT DEMOGRAPHICS
Initials:
Gender:
Birth Date:
M
F
ABO:
Institutional Approval Date:
A
B
AB
O
City/State of Residence:
Height:
Race:
Marital Status:
County if Ohio:
Weight:
BMI:
UNOS Status:
Transplant#:
PATIENT STATUS
UNOS Status: 1A
Lab MELD/PELD Score:
1B
Requested MELD/PELD Score:
Exception Points Requested: Yes
No
If Yes, justification:
MEDICAL DIAGNOSIS:
MEDICAL HISTORY (Please indicate nutritional status, infection, ascites, variceal hemorrhage, encephalopathy, etc.):
PATIENT SYMPTOMS
Yes
No
Ascites:
Yes
No
Hematemesis: Yes
No
Cardiac Issues: Yes
No
Pulmonary Issues: Yes
No
Dialysis:
Yes
No
Fatigue:
HCV
HCV: Yes
No
PCR:
Treatment: Yes
Genotype:
No
HCC
HCC: Yes
No
Size of largest lesion:
No. of Lesions:
Is this a resection candidate?
Yes
No
If not, why not?
Diagnosis confirmed by: Biopsy:
Yes
No
If not, why not?
NG/ml
alphafetaprotein (please enter value):
CT: Yes
No
HCC Treated: Yes
MRI: Yes
No
Total Size:
No
Chemoembolization: Yes
No
Ultrasound:
Yes
RFA: Yes
No
No
Resection: Yes
No
LABORATORY DATA
Renal
Patient
Lab Date
BUN
Creatinine
(v15.0528)
Liver Candidate Summary
Page 2 of 2
Hepatic
Patient
Lab Date
Patient
Lab Date
Patient
Lab Date
AST (SGOT)
ALT (SGPT
Alk Phos
Amylase
T Bili
PT
PTT
Albumin
INR
Other
WBC
HGB/HCT
Platelets
Calcium
Glucose
T Protein
Sodium
Potassium
Chloride
Ammonia
Serology
Anti HAV
HBsAg
Anti HBs
HBeAg
HBV DNA
Anti HBc
Anti HBe
Anti HCV
Method
HCV RNA
CMV IGG
CMV IGM
HIV
PSYCHOSOCIAL EVALUATION/QUALITY OF LIFE
(Support system, informed consent, attitude about transplant, aftercare, complications, etc.):
Insurance:
CHEMICAL DISORDER
(For patients with a diagnosis of substance use disorder & have been abstinent less than 12 months,
a CD Evaluation form must be attached)
Does patient meet DSM-5 diagnosis criteria for substance use disorder?
Does patient have more than 12 months of abstinence?
If less than 12 months, does this patient meet OSOTC CD (standard) criteria?
If less than 12 months, is an OSOTC CD Evaluation form attached?
Performed by:
Social Worker
Psychiatrist
Yes
Yes
Yes
Yes
No
No
No
No
Other:
Signature:
(v15.0528)