4. Clinical Guidelines for Liver Transplantation (PDF) - British ...

Guidebook for the Solid Organ Transplant Programme Chapter 4
Recipient Activation Form
BCT #: Activation Date:
Appendix N
dd/mmm/yyyy
Program:
Pancreas
Liver
Heart
Heart/Lung
Single Lung
Double Lung
Other: _________________
Tx Centre:
Tx No.: Date of Previous Tx: Previous Tx Prg:
VGH
SPH
CHH
Patient Name:
Date of Birth:
Pager #:
Home Phone#:
Work Phone #: Cell #:
Contact Name 1: Phone #:
Contact Name 2: Phone #:
Specialist: Phone #:
Family Physician: Phone #:
Activation Status:
Previous CT Surgery:
ABO:__________ Rh: ____________ Height (cm): ________ Weight(kg): __________
Cytotoxicity (PRA): Current: _____________ Date: _______________
Viral Screen: CMV: ______ CMV Tested Date:___________ HCV: ______ HIV: ________ EBV: _______
HbsAg(HBV):______ HBV Date Tested: _________ HbsAB: ____ HbcAB (Total): ________
VZV:____________ RPR: ____________ HBV DNA:_____ HSV:______
Comments:
Ascites:
No Small Moderate Large Unknown
HCV Genotype: ___________ PVR: _____________ X-Match:_________________
HCV Genotype Sub-Category: ____
TLC (Actual): __________ TLC (Predicted): ____________
Completed By:
Entered into PROMIS By:
Date:
Date:
Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 59
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