1144 E. Home Road, Suite B • Springfield, Ohio 45503-2797
Phone (614) 504-5705 • Fax (614) 504-5707
www.osotc.org
SMALL BOWEL SUMMARY
Liver
Pancreas
Stomach
Duodenum
OSOTC Patient Number:
PATIENT DEMOGRAPHICS
Initials:
Gender:
Birth Date:
M
F
ABO:
A
Institutional Approval Date:
B
AB
O
City/State of Residence:
Height:
Race:
Marital Status:
County if Ohio:
Weight:
BMI:
UNOS Status:
Transplant#:
PATIENT STATUS
UNOS Status:
MELD/PELD Score (if applicable):
Donor Wt Range:
MEDICAL DIAGNOSIS:
Exception Points Requested: Yes
No
If Yes, justification:
MEDICAL HISTORY (Please indicate nutritional status, infection, ascites, variceal hemorrhage, encephalopathy, etc.):
LABORATORY DATA
Renal
Patient
Lab Date
Normal Range
Patient
Lab Date
Normal Range
Patient
Lab Date
Normal Range
BUN
Creatinine
Hepatic
AST (SGOT)
ALT (SGPT
Alk Phos
Amylase
T Bili
PTT
Albumin
INR
Other
WBC
HGB/HCT
Platelets
Calcium
Glucose
T Protein
Sodium
Potassium
Chloride
(v15.0528)
Small Bowel Candidate Summary
Page 2 of 2
Ammonia
Serology
Patient
Lab Date
Normal Range
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.):
Performed by:
Social Worker
Psychiatrist
Other:
Insurance:
(v15.0528)