Kidney Pancreas Transplant Review And Referral Form (Page 2 of 4) in pdf

UNC Center for Transplant Care

Renal/Pancreas Transplant Review and Referral Form

Part I

*Name: ________________________________________________*S ocial Security #: ___________________________

*Address: _______________________________________*City:__________________________*State:______________

*Zip Code: _________*County: _____________Phone (H): ___________________Phone (Cell):____________________

*Date of Birth:_________________Sex: _________ *Race ___________ *Height:__________*Weight:_______________

*Patient’s EMAIL (if applicable)________________________________________________________________________

*Cause of ESRD: ________________________________________Diabetes: _____Yes _____No

Referral for combined Kidney/Pancreas transplant?

_____Yes

_____No

*Current Modality: _____CAPD

_____CCPD

_____ICHD

_____Home Hemo

_____None

Dialysis Days:

_____M-W-F

_____T-T-S

_____AM

_____PM

Does patient have transportation? _____ What form of transportation? (personal vehicle, county van, etc.)____________

Date of 1

Dialysis:_____________________Current Dialysis Center:__________________________________ _____

Dialysis Phone number___________________________ Fax number_________________________________________

Has patient ever been seen at UNC Hospitals? _____Yes _____No _____Unknown

UNC Medical Record Number: __________________________________

Type of Insurance: Medicaid____ Medicare ____ BCBS ____ Other_________________None_________

H/O Malignancy

_____Yes

_____No

Suspected Substance Abuse

_____Yes

_____No

Is patient compliant with dialysis? ____Yes

____No

Is patient compliant with meds? ____Yes

____No

Active HIV:

_____Yes

_____No

If HIV(+) please send current Viral Load and CD4 count (viral load must be undetectable, CD4 ct must be >200)

Patient declines transplant:

_____Yes

_____No

Previous Transplant

_____Yes

_____ No

Patient has received transplant education information locally:

_____Yes

_____No

_________________________________________________________________________________________________

*Referring Nephrologist’s Assessment as to Transplant Candidacy/Opinion:

I feel this patient is an: _____Acceptable Referral OR

_____Unacceptable Referral for Transplant Evaluation

_____Cardiovascular status precludes transplant

_____Pulmonary status precludes transplant

_____Level of understanding and compliance precludes transplant _____Recurrent infections preclude transplant

Note other medical problems that may preclude or place patient at an increased risk for transplant:

________________________________________________________________________________________________

_____ I do not anticipate this patient will be a candidate for transplant now or in the future due to:

_______________________________________________________________________________________________

_________________________________/______________________________________Date:____________________

Signature of referring Nephrologist

Print Name

* Indicates these m ust be completed

February 2015

Kidney Pancreas Transplant Review And Referral Form Page 2

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