Email of the individual to receive 30-day followup email
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Primary Hospital
* must provide value
Arkansas Children's Hospital Boston Children's Hospital C.S. Mott Children's Hospital Children's Healthcare of Atlanta Children's Hospital at Montefiore Children's Hospital Colorado Children's Hospital Los Angeles Children's Hospital New Orleans Children's Hospital of Michigan Children's Hospital of Philadelphia Children's Hospital of Pittsburgh Children's Hospital of Richmond at VCU Children's Hospital of Wisconsin Children's Medical Center of Dallas Children's Mercy Kansas City Children's Minnesota Children's National Medical Center Children's Nebraska Children's of Alabama Cincinnati Children's Hospital Cleveland Clinic Children's Hospital Cohen Dell Children's Medical Center of Central Texas Duke Children's Hospital Hassenfeld Children's Hospital at NYU Langone Medical Center Heart Institute Brazil Helen Devos Children's Hospital Hospital for Sick Kids Inova Joe DiMaggio Children's Hospital Johns Hopkins All Children's Hospital Johns Hopkins Children's Center Le Bonheur Children's Hospital Levine Children's Hospital Loma Linda University Children's Hospital Lucile Packard Children's Hospital Lurie Children's Hospital of Chicago Medical University of South Carolina Children's Health Memorial Hermann Mississippi Monroe Carell Jr. Children's Hospital at Vanderbilt Morgan Stanley Children's Hospital of NY Presbyterian Mount Sinai Kravis Children's Heart Center Nationwide Children's Hospital Nemours Children's Hospital - Delaware Norton Children's Hospital Ochsner Hospital for Children Oklahoma Phoenix Children's Hospital Primary Children's Hospital Rady Children's Hospital San Diego Riley Children's Hospital Seattle Children's Hospital St. Louis Children's Hospital Stollery Children's Hospital Texas Children's Hospital UCLA Mattel Children's Hospital UCSF Benioff Children's Hospital UF Health Shands Children's Hospital University of Wisconsin/American Family Children's Hospital University of Iowa Stead Family Children's Hospital University of Minnesota Yale New Haven Children's Hospital
View equation Patient's full name initials: FIRST Name
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Patient's full name initials: MIDDLE Name
* must provide value
Patient's full name initials: LAST Name
* must provide value
Patient's Full Name Initials:
First Name Initial Middle Name Initial Last Name Initial
Patient Initials concatenate
View equation
Patient's Date of Birth: MONTHnumeric only
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MM (1-12)
Patient's Date of Birth: DAYnumeric only
* must provide value
DD (1-31)
Patient's Date of Birth: YEARnumeric only
* must provide value
Year YYYY
View equation
View equation
View equation Patient's Date of Birth:
Month (MM): Day (DD): Year (YYYY):
ACTION QI ID** No data to be entered here. Make note of ACTION QI ID ______ -______ -______ Now M-D-Y H:M
Date of referral (not consultation):
Today M-D-Y MMDDYYYY
Date of consultation:
* must provide value
Today M-D-Y MMDDYYYY
Did the initial consultation occur as an inpatient or outpatient?
Inpatient
Outpatient
Age at consultation:(in 0.5 years)
0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 20.5 21 21.5 22 22.5 23 23.5 24 24.5 25 25.5 26 26.5 27 27.5 28 28.5 29 29.5 30 30.5 31 31.5 32 32.5 33 33.5 34 34.5 35 35.5 36 36.5 37 37.5 38 38.5 39 39.5 40 >40
Sex (at Birth):(select only one response)
Male
Female
Age at Fontan:(in 0.5 years)
0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 20.5 21 21.5 22 22.5 23 23.5 24 24.5 25 25.5 26 26.5 27 27.5 28 28.5 29 29.5 30 30.5 31 31.5 32 32.5 33 33.5 34 34.5 35 35.5 36 36.5 37 37.5 38 38.5 39 39.5 40 >40
The option "
Race:(choose all responses that apply)
The option "
Ethnicity:(select only one response)
Does the patient need an interpreter?
Yes
No
Is the patient's primary cardiologist employed at the HF consultation center?
Yes
No
Is the patient's primary cardiologist from a Fontan multidisciplinary clinic?
Is the patient's primary cardiologist a HF cardiologist?
Yes
No
Was a reason for referral specified?
Yes
No
Specify reason for referral:(choose all responses that apply)
Specify other referral reason:
Last assessment of systemic ventricle systolic function prior to referral:
Echo MRI Cath
Systemic ventricle systolic function:
Normal
Mildly depressed
Mild-mod
Mod
Mod-severe
Severe
Systemic ventricle systolic function:
Normal
Mildly depressed
Mild-mod
Mod
Mod-severe
Severe
Systemic ventricle systolic function:
Normal
Mildly depressed
Mild-mod
Mod
Mod-severe
Severe
Last assessment of AV-Valve regurgitation prior to referral:
Echo MRI Cath
AV-Valve regurgitation:
Normal
Mild
Mild-mod
Mod
Mod-severe
Severe
None
AV-Valve regurgitation:
Normal
Mild
Mild-mod
Mod
Mod-severe
Severe
None
AV-Valve regurgitation:
Normal
Mild
Mild-mod
Mod
Mod-severe
Severe
None
Patient weight at consultation:
kg
Patient height at consultation:
cm
Did the patient have an exercise test within the last 6 months
Yes
No
mL/kg/min
Did the patient have a 6 minute walk within the last 6 months?
Yes
No
Did the patient report exercise intolerance at consultation visit?
Yes
No
Does the patient have a pacemaker?
Yes
No
Does the patient have an ICD?
Yes
No
History of arrhythmia in the last year prior to referral?
Yes
No
Is the patient receiving medical therapy for arrhythmia?
Yes
No
Is the patient on inotrope infusion at the time of consultation?
Yes
No
Did the patient have chronic/recurrent ascites?
Yes
No
Did the patient have chronic/recurrent pleural effusions?
Yes
No
Has the patient been hospitalized in the year leading up to referral for ascites/pleural effusions/peripheral edema/fluid overload?
Yes
No
How many times has he/she been admitted in the last year?
1 2 3 4 5 6 7 8 9 10 >10
Has the patient had new or increased diuretic therapy in the year leading up to referral?
Yes
No
Has the patient had a Cath in the last 2 years?
Yes
No
Most representative Fontan pressure:
%
1 2 3 4
Does the patient have clinically significant PLE or is the patient receiving chronic therapy to treat PLE at the time of referral?
Yes
No
Does the patient receive chronic albumin infusions?
Yes
No
# of admissions for PLE in 12 months prior to referral:
Does the patient have clinically significant plastic bronchitis or is the patient receiving chronic therapy to treat plastic bronchitis at the time of referral?
Yes
No
Has the patient had hemoptysis requiring urgent medical evaluation?
Yes
No
Does the patient have imaging evidence of liver fibrosis?
Yes
No
Does the patient have synthetic liver dysfunction in his or her baseline state?
Yes
No
Synthetic liver dysfunction includes elevated INR in the absence of anticoagulation with warfarin, abnormally low platelets, abnormally low pre-albumin and other markers
If yes, specify the laboratory abnormality noted:
Serum bilirubin at consultation:
Serum Cr at consultation:
Serum cystatin C at referral:
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