Cadaver / Deceased Donor Transplantation Waiting List Pre-Operative Recipient Workup Form

---

Name*:

Date:*

Age*:

Gender:
MaleFeMale

Blood Group*: Select O+ O- A+ A- B- B+ AB+ AB-

Weight(kgs)*:

Height(cms)*:

BMI:*

Tel No. (S)*:

Mobile No. (S)*:

Marital Status:
MarriedUn-MarriedSeperate

Occupation*:

No. of Children*:

Brother's*:

Sister's*:

Previous Surgery (add if any):

Contact Person*:

Email Address*:

Address*:

City*:

State*:

Country*:

Relevant PMH & Medication

Tuberculosis:

YesNo

Diabetes Mellitus:

YesNo

Hypertension:

YesNo

Jaundice/Hepatitis:

YesNo

Asthma:

YesNo

Thyroid:

YesNo

Others:

YesNo

Other Medication*:

Clinical Data

Primary Diagnosis:

Organ*: --Select-- Kidney Transplant Liver Transplant Heart Transplant Lung 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 History

Alcohol: YesNo

Smoking: YesNo

Tobacco: YesNo

HBV Vaccination:

Code: