ITR Update 2009 - Patient Update Form

INTESTINAL TRANSPLANT REGISTRY:

To be used for Patient Update -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)*
Sex
Optional - Chart Number
*Patient Status as of May 31, 2009*
If Alive		Renal Replacement Therapy	In the from of Dialysis In the form of Kidney Transplant
If Deceased		Sepsis/Infection Lymphoma Graft Rejection Technical(thrombosis, non-functioning graft) Other
	Other
	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 therapy given
Modified Karnofky Performance Score
Lymphoproliferative Disease		Yes/No	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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