Marrow Donor Program Belgium - Registry
Motstraat 40 2800 Mechelen
Tel: (32) - 15 44 33 96
Fax: (32) - 15 44 36 56
Email: MDPB-registry@rodekruis.be
PRELIMINARY SEARCH REQUEST INTERNATIONAL PATIENT
Date of Request:
Patient ID :
Type of Search to be performed:
Stem Cell Donors Only
Cord Blood Units Only
Stem Cell Donors & Cord Units
Last Name:
Is this search urgent?
Yes
No
Are mismatches accepted?
Yes
No
First Name:
Date of Birth:
Gender:
Male
Weight:
kg
CMV Status:
Positive
Unknown
(Day/Month/Year)
Female
Diagnosis:
(please complete disease list in attachment)
Blood group:
Negative
Date of Diagnosis:
Diagnostic comment:
Patient Class I typing results:
A
B
C
HLA typing Labo:
First antigen:
Second antigen:
Testing method:
Date of typing:
Sero.
DNA
Patient Class II typing results:
DRB1
Sero.
DNA
DRB3/4/5
Sero.
DNA
DQB1
DPB1
First antigen:
Second antigen:
Testing method:
Sero.
ARE HAPLOTYPES IDENTIFIED:
DNA
YES
TRANSPLANT CENTER:
Telephone:
MDPB001a preliminary search request v2 2011
Sero.
DNA
Sero.
DNA
Sero.
DNA
NO
TRANSPLANT COORDINATOR:
Fax:
Email:
Pag. 1/3
Marrow Donor Program Belgium - Registry
Motstraat 40 2800 Mechelen
Tel: (32) - 15 44 33 96
Fax: (32) - 15 44 36 56
Email: MDPB-registry@rodekruis.be
PRELIMINARY SEARCH REQUEST INTERNATIONAL PATIENT
DISEASE CATEGORIE
PATIENT ID:
Acronym
NAME OF PATIENT:
Disease category
Check
Disease/stage
Idiopathic aplasia
Secondary post hepatic medullary aplasia
Secondary idiopathic medullary aplasia
Secondary toxic medullary aplasia
SAA
Severe Aplastic Anemia
Other secondary medullary aplasia
Paroxysmal nocturnal hemoglobinuria
Fanconi anemia
Other constitutional aplasia
Other non constitutional aplasia
Sickle cell anemia
IEA
Inherited Erythrocyte
Abnormality
Thalassemia
Other: PLEASE SPECIFY:
1st or 2nd complete remission (CR)
ALL
Acute Lymphoblastic
Leukaemia
3rd+ CR
1st or 2nd relapse
3rd+ relapse
CR
AML
Acute Myelogenous
Leukaemia
1st and 2nd relapse
3rd+ relapse
Chronic phase (CP) 1
CML
Chronic Myelogenous
Leukaemia
CP 2+
Accelerated phase
Blast phase
MDS
Myelodysplastic
disorders
PCD
Plasma Cell disorders
MDPB001a preliminary search request v2 2011
Highest IPSS<1.5
Highest IPSS>1.5
Multiple myeloma
Leukemia with plasmocytes
Pag. 2/3
Marrow Donor Program Belgium - Registry
Motstraat 40 2800 Mechelen
Tel: (32) - 15 44 33 96
Fax: (32) - 15 44 36 56
Email: MDPB-registry@rodekruis.be
PRELIMINARY SEARCH REQUEST INTERNATIONAL PATIENT
PATIENT ID:
Acronym
NAME OF PATIENT:
Disease category
Check
Disease/stage
Refractory to Fludarabine
CLL
Chronic Lymphocytic
Leukemia
With Del p53 (17p-)
None of the above
Severe combined immunodeficiency
Combined immunodeficiency
IIS
Ommen syndrome
Inherited Immune
System Disorder
Wiskott Aldrich syndrome
Ataxia Telangiectasia
Other: PLEASE SPECIFY:
HL
CR1
Hodgkin's Lymphoma
Other
CR1
NHL
Non-Hodgkin's
Lymphoma
Other: PLEASE SPECIFY:
Histology:
Grade:
Amegacaryocytosis
IPA
Inherited Platelet
Abnormality
Glanzmann Thrombastenia
Other : PLEASE SPECIFY:
Hurler Syndrom
IMD
Inherited Metabolic
Disorder
Adrenoleucodystrophia
Other: PLEASE SPECIFY:
Histiocytosis
HIS
Histiocytic Disorders
Familial lymphohistiocytosis
Other: PLEASE SPECIFY:
Myelofibrosis
OM
Other Malignancy
OND
Other Non-Malignant
Disease
Polycythemia vera (Vaquez)
Essential trombocytemia
Other: PLEASE SPECIFY:
MDPB001a preliminary search request v2 2011
PLEASE SPECIFY:
Pag. 3/3