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Cadaver Registration
Cadaver Liver Transplantation Waiting List Pre-Operative Recipient Workup Form
Name
*
:
Date
*
:
Age
*
:
Gender :
Male
FeMale
Blood Group
*
:
Select
O+
O-
A+
A-
B-
B+
AB+
AB-
Weight (Kgs):
*
:
Height (cms)
*
:
BMI
*
:
Tel No. (S):
*
:
Mobile No (S):
*
:
Marital Status: :
Married
Un-Married
Occupation
*
:
No. of Children
*
:
Select
1
2
Brother's
*
:
Select
1
2
Sister's
*
:
Select
1
2
Previous Surgery
*
:
Contact Person
*
:
Email address
*
:
Address
*
:
City
*
:
State
*
:
Country
*
:
Relevant PMH & Medication
:
Tuberculosis :
Yes
No
Diabetes Mellitus :
Yes
No
Hypertension :
Yes
No
Jaundice/Hepatitis :
Yes
No
Asthma :
Yes
No
Thyroid :
Yes
No
Others :
Yes
No
Other Medication
*
:
Clinical Data
Primary Diagnosis:
Organ
*
:
--Select--
Kidney Transplant
Liver Transplant
Heart Transplant
Problem List:
1
2
Child-Pugh Score
( A=5-6; B=7-9; C=10-15 )
Albumin:
Bilirubin:
INR:
Encephalopathy:
Ascites:
MELD Score:
Personal H/O
Alcohol :
Yes
No
Smoking :
Yes
No
Tobacco :
Yes
No
HBV Vaccination:
Code:
