PATIENT REFERRAL – EBMT MINIMUM DATA REQUIRED INITIAL DIAGNOSIS

ISSUE 4 DEAR PATIENT WELCOME TO
PATIENT DATA FORM FOR ADULTS (AGED 15
PATIENT GUIDE TO ACL INJURIES WHAT IS

PATIENT HISTORY NAME AGE DATE 1 DESCRIBE
PATIENT ID NUMBER PATIENT NAME INFORMED CONSENT
PULMONARY REHABILITATION COMMUNITY REFERRAL PATIENT NAME………………………………NHS

Bone marrow failure syndrome (including aplastic anaemia)

PATIENT REFERRAL – EBMT MINIMUM DATA REQUIRED

INITIAL DIAGNOSIS

BONE MARROW FAILURE SYNDROME (INC APLASTIC ANAEMIA)

Name:

DOB:

NHS No.


Primary Diagnosis: Date of Initial Diagnosis:--------



Type: Acquired --------- Etiology ----------- Genetic -------------








RESULTS AT DIAGNOSIS

(Please enter results below and attach related reports)


Cytogenetics:

(Tick if results available and attach report): ---------------------------



(For the below, please add result and attach any reports)


Hb(g/dL):--------------------





Platelets (109/L) ------------


Not evaluated Untransfused Transfused


Neutrophils(109/L) --------------------------------------


Reticulocytes (109/L) -----------------------------------


Ferritin ng/ml ---------------------------------------------



Complications


Haemorrhages







Yes No Not evaluated Unknown



Systemic infection:


Yes No Not evaluated Unknown






















































.


PNH Tests: (For Aplastic anaemia on PNH at diagnosis):


Date of PNH Test:


PNH diagnostics by flow cymetry or other (specify)




Clone absent Clone present Not evaluated


Size of PNH clone in %


Flow cytometry assessment done on:


Granulocytes RBC Both Not done


Other, specify



Clinical manifestations of PNH: Yes --- No---






























Clinical manifestations of PNH: Yes--- No---
















Not evaluated Untransfused Transfused



















Yes No Not evaluated Unknown



Resistance to random platelets



















Patient treated as part of a clinical trial?


Yes: --------------------------------- No: ---------------------------


Name of Trial -------------------



Immunosuppressive treatment given to the patient from time of diagnosis to referral for Transplant

(Tick box and complete dates where requested)


Was the patient treated before the HSCT transplant?


Yes:---------------------------------- No:-------------------------



Date Started:-------- Sequential number of this treatment:--------------


If 1st treatment episode for the patient ever:

Number of Transfusions befor the 1st treatment:


RBC (Units):


<20 20-50 >50 None Unknown


Platelets (Units):


<20 20-50 >50 None Unknown


OR:


If patient has been treated before(Immunosuppressive therapy or HSCT)

(Data must have been collected within 3 months prior to the treatment), (For the below, please add result and attach any reports)


Hb(g/dL)----------------------


Not evaluated---- Untransfused---- Transfused----


Platelets (109/L)-----------


Not evaluated--- Untransfused---- Transfused----


Neutrophils(109/L)-------- Reticulocytes (109/L)-------- Ferritin ng/ml -------




Reason for this treatment


Failure of first line of therapy----- Relapse------------------------------ PR to previous treatment--------


Secondary clonal disorder-------- Other---------------------------------- Unknown ----------------------------



Chemo Regimen:


Response to this Immunosuppressive Treatment episode:


CR PR No response Progression Not evaluable


Other, specify Unknown



Date response evaluated -----------

































University Hospital Southampton NHS Foundation Trust Date: January 2014



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Tags: diagnosis bone, of diagnosis, initial, diagnosis, patient, minimum, referral, required