Email of the individual to receive 30-day followup email
* must provide value
Primary Hospital* must provide value
Boston Children's Hospital C.S. Mott Children's Hospital Children's Hospital at Montefiore Children's Healthcare of Atlanta Children's Hospital Colorado Children's Hospital of Philadelphia Children's Hospital of Pittsburgh Children's Hospital of Wisconsin Children's Medical Center of Dallas Children's Mercy Kansas City Children's National Medical Center Children's of Alabama Cincinnati Children's Hospital Dell Children's Medical Center of Central Texas Hospital for Sick Kids Joe DiMaggio Children's Hospital Le Bonheur Children's Hospital Loma Linda University Children's Hospital Lucile Packard Children's Hospital Lurie Children's Hospital of Chicago Monroe Carell Jr. Children's Hospital at Vanderbilt Morgan Stanley Children's Hospital of NY Presbyterian Nationwide Children's Hospital Norton Children's Hospital Ochsner Hospital for Children Phoenix Children's Hospital Primary Children's Hospital Riley Children's Hospital Seattle Children's Hospital St. Louis Children's Hospital Stollery Children's Hospital Texas Children's Hospital UCSF Benioff Children's Hospital UF Health Shands Children's Hospital University of Minnesota
Patient's full name initials (First, Middle, Last)
Patient's Date of Birth mmddyyyy (no dashes, no spaces)
Calculated Year View equation
ACTION QI ID______ -______ -______
Form Start Timestamp Now M-D-Y H:M
Date of referral (not consultation)? if known
Today M-D-Y
Date of consultation?* must provide value
Today M-D-Y
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 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
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
If yes, what was it (free text)
Last assessment of systemic ventricle systolic function prior to referral: Echo MRI Cath
For Echo, systemic ventricle systolic function: Normal
Mildly depressed
Mild-mod
mod
mod-severe
Severe
For MRI, systemic ventricle systolic function: Normal
Mildly depressed
Mild-mod
mod
mod-severe
Severe
For Cath, 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
For Echo, AV-Valve regurgitation: Normal
Mild
Mild-mod
Mod
Mod-severe
Severe
None
For MRI, AV-Valve regurgitation: Normal
Mild
Mild-mod
Mod
Mod-severe
Severe
None
For Cath, 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
If yes - max VO2 (number) mL/kg/min
Did the patient have a 6 minute walk within the last 6 months Yes
No
If yes - distance walked
If yes , lowest O2 saturation
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
VEDP
most representative Fontan pressure
Cardiac Index
systemic saturation (%)
NYHA class 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
Serum BUN at referral
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