3 Living Donor Follow Up Form.xlsx

			Living Donor Follow Up (LDF)
			Fields to be completed by members
			Form Section	Field Label	Notes
				Urinalysis
			1-Provider Information	Recipient Center Code
			1-Provider Information	Recipient Center Code	Display Only - Cascades from Database
			1-Provider Information	Recipient Center Type	Display Only - Cascades from Database
			1-Provider Information	Recipient Center Name
			1-Provider Information	Follow Up Code	Display Only - Cascades from Database
			1-Provider Information	Follow-Up Center Code	Display Only - Cascades from Database
			1-Provider Information	Follow-Up Center Type	Display Only - Cascades from Database
			1-Provider Information	Followup Center Code
			1-Provider Information	Followup Center Provider Number//Followup Center
			1-Provider Information	Followup Center Name//Followup Center
			2-Donor Information	Last Name	Display Only - Cascades from Database
			2-Donor Information	First Name	Display Only - Cascades from Database
			2-Donor Information	DOB	Display Only - Cascades from Database
			2-Donor Information	SSN	Display Only - Cascades from Database
			2-Donor Information	Gender	Display Only - Cascades from Database
			2-Donor Information	Donor ID	Display Only - Cascades from feedback
			2-Donor Information	Recovery Date	Display Only - Cascades from Database
			2-Donor Information	Organ(s) Recovered	Display Only - Cascades from Database
			3-Donor Status	Date of Initial Discharge	Display Only - Cascades from Database
			3-Donor Status	Most Recent Donor Status since//Date of last contact or death
			3-Donor Status	Most Recent Donor Status since
			3-Donor Status	Cause of Death
			3-Donor Status	Cause of Death//Specify
			3-Donor Status	Functional Status
			3-Donor Status	Physical Capacity
			3-Donor Status	Working for Income
			3-Donor Status	Working for Income//If No, Not Working Due To
			3-Donor Status	Working for Income//If Yes
				Donor Status//Attempts to Collect
			3-Donor Status	Loss of medical insurance due to donation
			3-Donor Status	Loss of health insurance
			3-Donor Status	Loss of life insurance
			4-Clinical Information	Date
			4-Clinical Information	Current weight
			4-Clinical Information	Weight in Lb
			4-Clinical Information	Weight //Status	Value or status is reported, not both
			4-Clinical Information	Height in Ft
			4-Clinical Information	Height in In
			4-Clinical Information	ER or urgent care visit related to donation since last follow-up
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	Total Bilirubin
			5-Liver Clinical Information	Total Bilirubin //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	SGOT/AST
			5-Liver Clinical Information	SGOT/AST //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	SGPT/ALT
			5-Liver Clinical Information	SGPT/ALT //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	Alkaline Phosphatase
			5-Liver Clinical Information	Alkaline Phosphatase //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	Serum Albumin
			5-Liver Clinical Information	Serum Albumin //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	Serum Creatinine
			5-Liver Clinical Information	Serum Creatinine //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	INR
			5-Liver Clinical Information	INR //Status	Value or status is reported, not both
			5-Liver Clinical Information	Date
			5-Liver Clinical Information	Platelet Count
			5-Liver Clinical Information	Platelet Count//Status	Value or status is reported, not both
			6-Kidney Clinical Information	Date
			6-Kidney Clinical Information	Kidney//Serum Creatinine
			6-Kidney Clinical Information	Kidney Serum Creatinine //Status	Value or status is reported, not both
			6-Kidney Clinical Information	Date
			6-Kidney Clinical Information	Blood Pressure Systolic
			6-Kidney Clinical Information	Blood Pressure Systolic //Status	Value or status is reported, not both
			6-Kidney Clinical Information	Date
			6-Kidney Clinical Information	Blood Pressure Diastolic
			6-Kidney Clinical Information	Blood Pressure Diastolic //Status	Value or status is reported, not both
			6-Kidney Clinical Information	Donor Developed Hypertension Requiring Medication
			6-Kidney Clinical Information	Protein-Creatinine Ratio
			6-Kidney Clinical Information	Urine Protein
			6-Kidney Clinical Information	Maintenance Dialysis
			6-Kidney Clinical Information	Maintenance Dialysis//If Yes, Date First Dialyzed
			6-Kidney Clinical Information	Diabetes
			6-Kidney Clinical Information	Diabetes
			7-Lung Clinical Information	Activity Level
			7-Lung Clinical Information	Chronic Incisional Pain
			8-Complications	Has the donor been readmitted since
			8-Complications	If Yes, Date of First Readmission
			8-Complications	Date of First Readmission //Status	Value or status is reported, not both
			8-Complications	Specify Reason for First Readmission
			8-Complications	Complications since	Display Only - Cascades from Database
			8-Complications	Kidney Complications since	Display Only - Cascades from Database
			8-Complications	Kidney Complications Status//If Yes
			8-Complications	Kidney Complications//Specify
			8-Complications	Liver Complications since	Display Only - Cascades from Database
			8-Complications	Liver Complicatons Status//If Yes
			8-Complications	Liver Complications//Specify
			8-Complications	Complications//Specify
			9-Recipient Information	Recipient's Last Name	Display Only - Cascades from Database
			9-Recipient Information	Recipient's First Name	Display Only - Cascades from Database
			9-Recipient Information	Recipient's SSN	Display Only - Cascades from Database
			9-Recipient Information	Recipient's Name	Display Only - Cascades from Database
			9-Recipient Information	Transplant Date	Display Only - Cascades from Database
				Public Burden Statement