ITR Update 2009 - NEW Patient Form

INTESTINAL TRANSPLANT REGISTRY:

To be used for New Patients -ONLY-

IMPORTANT: Please read Carefully

-If Possible fill in all the items in the form. -All the dates use the following format: MM/DD/YYYY eg. 03/12/2009 = MARCH 12, 2009

*(asterisc) denotes mandatory field. Information must be entered in order to submit the form

Patient Demographics

Centre*
Patient Initials*
Patient date of Birth (MM/DD/YYYY)*
Date of Transplant (MM/DD/YYYY)*
Patient Sex
Optional - Chart Number
*Patient Diagnosis* Short Gut (Masive Intestinal Resection)		Volvulus Gastroschisis Trauma Necrotizing Enterocolitis Ischemia/Thrombosis/Embolus Crohn's Disease Intestinal Atresia Other
	If Other, please specify
Mucosal Defects		Microvillus Inclusion Sacretory Diarrhea Autoimmune Enteritis Other
	If Other, please specify
Motility Disorder		Pseudo-obstruction Syndrome Aganglionosis Hirschprung's Disease Other
	If Other, please specify
Tumor/Cancer		SelectDesmoid Gardner's Syndrome Familial Polyposis Other
	If Other, please specify
Retransplant		Yes/No
If Other, please specify
Donor Information Donor type
Graft Storage Time (HH:MM)
Graft Number


Recipient Information
Status at Time of Transplant
ABO Compatibility
Venous Drainage of Isolated Intestinal Grafts (only)
Native Organs Resected (organs removed from recipient patient -if any-)		Stomach Duodenum Pancreas Kidneys Liver Other
Organs Transplanted		Stomach Duodenum Pancreas Small Bowel Colon Liver Reduced Liver Kidney Other
	If Other, please specify
Induction Immunosupression		None Anti-lymphocyte Product (ATG/ALG) Alemtuzumab (CamPath) Bone Marrow Cyclophosphamide (Cytoxan) Daclizumab (Zenapax/Simulect) Other
Maintenance Immunosuppression		None Anti-lymphocyte Product (ATG/ALG) Alemtuzumab (CamPath) Bone Marrow Cyclophosphamide (Cytoxan) Daclizumab (Zenapax/Simulect) FK-506-Tacrolimus-Prograf Cyclosporine-Sandimune/Neoral Orthoclone OKT3/Muromonab CD3 Azathioprine/Imuran Prednisone (Solu-Medrol/Cortef) Mycophenolate Mofetil (CellCept/Myfortic) Rapamycin Sirolimus/Rapamune) Deoxyspergualin Other
	If Other, please specify
Patient Status
If discharged, date of Discharge (MM/DD/YYYY)

*Patient Status as of May 31, 2009*
If Alive:		Renal Replacement Therapy (yes/no)	In the form of Dialysis In the form of Kidney Transplant
If Deceased	Cause of death (please specify):	Sepsis/Infection Lymphoma Graft Rejection Technical(thrombosis, non-functioning graft) Other
	If Other, please specify
	Date of Death (MM/DD/YYYY)
If Lost Follow-UP	Date of last contact (DD/MM/YYYY)
Current Immunosuppression as of May, 31 2009 (or prior to graft removal/death)
Please specify therapy (if applicable)		FK-506-Tacrolimus-Prograf Cyclosporine-Sandimune/Neoral Rapamycin (Sirolimus/Rapamune) Prednisone (Solu-Medrol/Cortef) Azathioprine/Imuran Mycophenolate Mofetil (CellCept/Myfortic) Deoxyspergualin Other
	If Other, please specify
Modified Karnofky Performance Score
Lymphoproliferative Disease		Yes/No	If Yes: Resolved Ongoing Died
*Was the Graft Intact as of May 31, 2009 or at time of death?*
If intact
If removed	Date of Graft removal (DD/MM/YYYY)
	Reason for Graft Removal
How many times has the Patient been Hospitalized in the past 12 months?
Attach Patient PDF form
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