Questionnaire for review

Serial number:

Name: AGE/SEX:

UHID: Occupation:

Part A
1. What is the current status of the patient? (how is he/she)
a. If death: date of death.
2. When were you advised for transplant? (if they say never advised, please note)

3. Did the patient undergo transplant elsewhere?

a. Yes/no. if yes whether DDLT or LDLT
b. Date
c. Patient doing well or no
4. Does the patient or relative intend to get a transplant in the near future?

YES NO
1. Do they want to come back here 1. Are there financial issues
2. Are they arranging finances 2. Is there no donor?
3. Are they looking for a donor 3. Patient himself doesn’t want it
_______________________________________________or he is getting better

4. Is the patient condition improving or deteriorating meanwhile they are waiting

5. Not willing because advised by other physician or advised by this surgical team since
patients are improving.

6. Last visit to a doctor: advise

7. Readmission: reasons and number of time readmitted

a. interventions

1. Last labs : Bilirubin , INR, Creatinine, Sodium