3 Month Followup Pedimacs - UAB

3 Month Followup Pedimacs

Followup Status (3 Month Followup (+/ 1 month))

Pump Change

Select one of the following Inpatient Outpatient Other Facility Unable to obtain followup information

Followup date

Facility Type Nursing Home/Assisted Care Hospice Another hospital Rehabilitation Facility Unknown

State reason why you are unable toobtain followup information:

Patient didn't come to clinic Not able to contact patient Not addressed by site

Was patient intubated? Yes No Unknown

Was patient on dialysis? Yes No Unknown

Current Device Strategy Bridge to Recovery Rescue Therapy Bridge to Transplant (patient currently listed for transplant) Possible Bridge to Transplant Likely to be eligible Possible Bridge to Transplant Moderate likelihood of becoming eligible Possible Bridge to Transplant Unlikely to become eligible Destination Therapy

List Date for Transplant

ST= Unknown

Pump Exchange Yes No Unknown

If yes, please select one of thefollowing:

Intracorporeal device Para or Extra corporeal device Upsizing device because of patient growth status All other reasons would categorize the pump change as a Device

Malfunction

Please select appropriate reason: Thrombus NOT associated with hemolysis Change in hemodynamics Clinical status Device parameters

version date: 12/19/2016

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Functional Capacity

Excursions

ZONES

Hemolysis Zone

Was there a Console Change? Yes No Unknown

Date of console change

ST= Unknown

Original Console Name

New Console Name

Sedated Yes No Unknown

Paralyzed Yes No Unknown

Intubated Yes No Unknown

Ambulating Yes No Unknown

Primary Nutrition Orally Per feeding tube TPN Not Applicable

Has the patient had any nonmedically required excursions off

the unit?

Yes No Unknown Not Applicable

If yes, where (please select all thatapply)

Playroom Cafeteria Walk outside Sitting room General rehab None

Please enter the peak Plasmafreehemoglobin (PFH) since the last

followup visit:

ST= Unknown Not Done

What is your hospital’s upper limitof the normal range of peak PFH:



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3 Month Followup - Status

Enter the Maximum and Minimum HCT or HGB since the last Followup visit:

Has the following been present at any time since the last Followup period? Physical Findings (select all thatapply):

Right Heart Failure Zone

Clinical Findings – Since the last followup.

Please enter the peak serum lactatedehydrogenase (LDH) since the last

followup visit:


What is your hospital’s upper limitof the normal range of LDH:


Min. HCT:


Max. HCT:


Min. HGB:


Max. HGB:


Highest Total Bilirubin since the lastFollowup period:


Hemoglobinuria (TeaColoredUrine)?

Yes No Unknown

Pump malfunction and/or abnormalpump parameters?

Yes No Unknown

CVP or RAP > 16 mmHg? Yes No Unknown Not Done

Dilated Vena Cava with absence ofInspiratory Variation by Echo?

Yes No Unknown Not Done

Clinical findings of elevated jugularvenous distension at least half wayup the neck in an upright patient?

Yes No Unknown

Peripheral Edema? Yes No Unknown


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Ascites? Yes No Unknown

Has the patient been on Inotropessince the last Followup?

Yes No Unknown

If yes, select all that apply: Dopamine Dobutamine Milrinone Isoproterenol Epinephrine Norepinephrine Levosimendan Unknown Vasopressin Nitroprusside Fenoldopam Prostacyclin

Nesiritide? Yes No Unknown

Has the patient had a RVAD implantsince the last Followup or

rehospitalization?

Yes No Unknown

Has the patient experienced aNeurological Event since time of

implant?

Yes No Unknown

Modified Rankin Scale 0 – No symptoms at all 1 No Significant disability: despite symptoms: able to carry out all usual

duties and activities 2 Slight disability: unable to carry out all previous activities but able to

look after own affairs without assistance 3 Moderate disability: requiring some help, but able to walk without

assistance. 4 Moderately severe disability: unable to walk without assistance, and

unable to attend to own bodily needs without assistance. 5 Severe disability: bedridden, incontinent and requiring constant

nursing care and attention. 6 Dead

ST= Not Documented

Not Done

If yes, please enter the Modified Rankin Scale.


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Hemodynamics

General Hemodynamics

Invasive Hemodynamics

Systolic blood pressure mmHg

ST= Unknown Not done

Diastolic blood pressure mmHg


Mean Arterial Blood Pressure (MAP) mmHg


ECG rhythm Sinus Atrial fibrillation Atrial Flutter Paced: Atrial pacing Paced: Ventricular pacing Paced: Atrial and ventricular pacing Unknown Not done Other, specify

Height in

cm


Weight lbs

kg


Pulmonary artery systolic pressure

mmHg


Pulmonary artery diastolic pressure

mmHg


Mean RA Pressure mmHg


PVR wood units

ST= Unknown


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Not Done

Mean Pulmonary artery wedgepressure

mmHg


Central venous pressure (CVP) mmHg


Cardiac Index L/min/M2 (by Swan)


Was Cardiac Index Measured byFick or Thermodilution?

Yes No Unknown

Choose Method Fick Thermodilution


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3 Month Followup - Hemodynamics


Medications

Was the patient sent home with anIV?

Yes No Unknown

ACE inhibitors Yes No Unknown

Aldosterone antagonist Yes No Unknown

Amiodarone Yes No Unknown

Angiotensin receptor blocker drug Yes No Unknown

Antiplatelet therapy drug Yes No Unknown

Select drug(s) Aspirin Dextran Dipyridamole Clopidogrel Ticlopidine Unknown Other, specify

Thrombolytic Yes No Unknown

Betablockers Yes No Unknown

Digoxin Yes No Unknown

Loop diuretics Yes No Unknown

If yes, enter dosage: mg/day

ST= Unknown

Type of Loop Diuretic: Furosemide Torsemide Bumetanide Other


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Transfusion

Low molecular weight heparin(Lovenox, Fragmin, Innohep)

Yes No Unknown

Nitric oxide Yes No Unknown

Sildenafil/ Bosentan Yes No Unknown

UFH: Unfractionated Heparin Yes No Unknown

Warfarin (coumadin) Yes No Unknown

Arixtra (fondaparinux) Yes No Unknown

Did patient receive new IV or oralmedication to treat hypertension?

Yes No Unknown

Was there a Tranfusion? Yes No Unknown

If yes, enter number of PRBC (Totalnumber of cc's received)

ST= Unknown


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3 Month Followup - Medications


Laboratory

Sodium mEq/L

mmol/L


Potassium mEq/L

mmol/L


Blood urea nitrogen mg/dL

mmol/L


Creatinine mg/dL

umol/L


SGPT/ALT (alanineaminotransferase/ALT)

u/L


SGOT/AST (aspartateaminotransferase/AST)

u/L


LDH units/L, U/L, ukat/L


Total bilirubin mg/dL

umol/L


Bilirubin direct mg/dL

umol/L


Bilirubin indirect mg/dL

umol/L


Albumin g/dL

g/L


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Prealbumin mg/dL

mg/L


Total Cholesterol mg/dL

mmol/L

ST= < 50 mg/dL Unknown Not done

Brain natriuretic peptide BNP pg/ml

ng/L

ST= > 7500 pg/mL Unknown Not done

NT pro brain natriuretic peptide ProBNP

pg/ml

ng/L


White blood cell count x103/uL

x109/uL


Reticulocyte count %


Hemoglobin g/dL

g/L

mmol/L


Hemoglobin A1C %

mmol/mol

mg/dL

mmol/L


Estimated Average Glucose (eAG):

Platelets x103/uL

x109/uL



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3 Month Followup - Laboratory

international units


Plasmafree hemoglobin mg/dL

g/L


Positive antiheparin/plateletantibody (HIT)

Yes No Unknown

If Yes, are they on direct thrombininhibitors

Yes No Unknown

If Yes, Enter Drugs: Aspirin Dipyridamole Plavix Heparin Coumadin Direct thrombin inhibitors (ex: arg, lip, val…)

Was a TEG done? Yes No Unknown

ThrombElastoGraph HemostasisSystem (TEG) profile, MA k

max amplitude in kaolin


ThrombElastoGraph HemostasisSystem (TEG) profile, R k

reaction time in kaolin


ThrombElastoGraphHemostasisSystem (TEG) profile, R

h

reaction time w/heparinase


Sensitivity CRP mg/L


Lupus Anticoagulant Positive Negative Unknown


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3 Month Followup - Laboratory

INR


Device Flow Chart

Device Function

Device Parameters

Device Inspection

Left Flow LPM

ST= Unknown

Right Flow LPM

ST= Unknown Not Applicable

Left Fill Volume: ml

ST= Unknown

Right Fill Volume ml


Pump Rate BPM

ST= Unknown

Vacuum Pressure mm Hg


Left Drive Pressure mm Hg


Right Drive Pressure mm Hg


Auscultation Abnormal Normal Not Applicable

Device Flow Chart - TAH version date: 12/19/2016

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Device Flow Chart

Device Function

Device Parameters

Device Inspection

Pump Flow LPM

ST= Unknown

Pulsality Index

ST= Unknown

Pump Power Watts

ST= Unknown

Pump Speed RPM

ST= Unknown

Low Speed RPM

ST= Unknown


Driveline Abnormal Normal Not Applicable

Device Flow Chart - HeartMate II version date: 12/19/2016

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Device Flow Chart

Device Function

Device Parameters

Device Inspection

Pump Flow LPM

ST= Unknown

Pump Power Watts

ST= Unknown

Pump Speed RPM

ST= Unknown



Device Flow Chart - HVAD version date: 12/19/2016

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Device Flow Chart

Device Function

Device Parameters

Device Inspection

Device Funtion (RVAD)

Device Parameters (RVAD)

Device Inspection (RVAD)

Pump Flow LPM

ST= Unknown

Control Mode Synchronous Asynchronous Independent Not Applicable

Pump Rate BPM

ST= Unknown

Depositions Yes No Not Applicable

Depositions Description

Full Ejection Yes No Not Applicable

Systolic Pressure: mm Hg

ST= Unknown

Diastolic Pressure: mm Hg

ST= Unknown

Percent Systole: %

ST= Unknown

Pump Flow (RVAD) LPM

ST= Unknown

Control Mode (RVAD) Both Synchronous Asynchronous Independent Not Applicable

Pump Rate (RVAD) BPM

ST= Unknown

Depositions (RVAD) Yes

Device Flow Chart - EXCOR version date: 12/19/2016

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No Not Applicable

Depositions Description (RVAD)

Full Ejection (RVAD) Yes No Not Applicable

Systolic Pressure (RVAD): mm Hg

ST= Unknown

Diastolic Pressure (RVAD): mm Hg

ST= Unknown

Percent Systole (RVAD): %

ST= Unknown

Device Flow Chart - EXCOR version date: 12/19/2016

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Device Flow Chart

Device Function

Device Parameters

Device Inspection

Device Funtion (RVAD)

Device Parameters (RVAD)

Device Inspection (RVAD)

Pump Flow LPM

ST= Unknown

Pump Power Watts

ST= Unknown

Pump Speed RPM

ST= Unknown



Pump Flow (RVAD) LPM

ST= Unknown

Pump Speed (RVAD) RPM

ST= Unknown

Depositions AbNormal Normal Not Applicable

Device Flow Chart - Centrimag version date: 12/19/2016

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Exercise Function

All patients >= 10 years of age at time of implant should attempt to complete these functional capacity measurements especially for those patientsclassified as Intermacs patient profile level 47

Medical Condition

6 minute walk feet

ST= Not done Not done: too sick Not done: other Not done: age inappropriate

This requires an inside hall for which distances (in FEET) should be measured, preferably as long as possible to avoid frequent turns. Patients areinstructed to walk steadily to cover as much distance as possible during the 6 minutes. They are advised that they may stop if necessary during the6 minutes. The staff member performing the test should walk behind the patient to avoid undue influence on the pace. The distance coveredduring the 6 minutes in feet will be recorded here. NOTE: You may use the time from the first 15 feet of the 6minute walk for the Gait speedtest listed below (please see instructions for the gait speed test below.)

Gait Speed (1st 15 foot walk) seconds


Instructions: Record the time (seconds) required for the patient to walk the first 15 feet of the 6 minute walk. The “starting” line and the 15 foot lineshould be clearly marked. Record the time to the first footfall at 0 feet and ends with the first footfall at 15 feet in the nearest. 0.1 sec with astopwatch. NOTE: You may use the time from the first 15 feet of the 6 minute walk for the Gait speed test.

Peak VO2 Max mL/kg/min


Maximum volume of oxygen the body can consume during exercise (mL/kg/min) is the ml/kg/min of oxygen consumed during symptomlimitedexercise testing either on a bicycle or treadmill. The values recorded during the bicycle are usually 12 ml/min lower than for the treadmill, but it isassumed that most institutions will use only one instrument. If both are available, the bicycle is preferable as the mode easiest to standardize.

R Value at peak %


R Value at peak is the respiratory quotient of carbon dioxide production divided by oxygen consumption, and is used as an index of how vigorouslythe patient exercised. A value above 1.05 is generally considered to represent an adequate effort.

NYHA Class Class I: No limitation of physical activity; physical activity does not causefatigue, palpitation or shortness of breath.

Class II: Slight limitation of physical activity; comfortable at rest, butordinary physical activity results in fatigue, palpitations or shortness ofbreath.

Class III: Marked limitation of physical activity; comfortable at rest, butless than ordinary activity causes fatigue, palpitation or shortness of breath.

Class IV: Unable to carry on minimal physical activity without discomfort;symptoms may be present at rest.

Unknown


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Choose all indicated symptoms thatapply.

Mild tachypnea with feeds in infant Mild diaphoresis with feeds in infant Dyspnea on exercise in older children Unknown


Marked tachypnea with exertion or with feeding Marked diaphoresis with exertion or with feeding Unknown


Tachypnea Retractions Grunting Diaphoresis Unknown

Ross Classification of CongestiveHeart Failure

Ross Class I: No limitations or symptoms. Ross Class II: No growth failure. Ross Class III: Growth failure. Ross Class IV: Symptomatic at rest. Not applicable: >= 2 years of age Unknown


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3 Month Followup - Exercise Function and Trailmaking Data


Quality Of Life(QOL surveys cannot be administered after the visit date)

PedsQL

PHYSICAL FUNCTIONING (problems with...)

Did the child complete a form? Yes No Unknown

Please select the 'Child' form: PedsQL Young Child (57 yrs) PedsQL Child (812 yrs) PedsQL Teen (1318 yrs)

It is hard for you to walk: 0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

It is hard for you to run: 0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

It is hard for you to play sports orexercise:

0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

It is hard for you to pick up bigthings:


It is hard for you to take a bath orshower:


It is hard for you to do chores (likepick up your toys):


Do you have hurts or aches: 0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

3 Month Followup - Quality of Life Child (5-7 yrs) version date: 12/19/2016

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EMOTIONAL FUNCTIONING (problems with...)

SOCIAL FUNCTIONING (problems with...)

Where?

Do you ever feel too tired to play: 0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

Do you feel scared: 0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

Do you feel sad: 0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

Do you feel mad: 0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

Do you have trouble sleeping: 0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

Do you worry about what willhappen to you:


Is it hard for you to get along withother kids:


Do other kids say they do not wantto play with you:


Do other kids tease you: 0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

Can other kids do things that youcannot do:


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SCHOOL FUNCTIONING (problems with...)

VADQoL


It is hard for you to keep up whenyou play with other kids:


Is it hard for you to pay attention inclass:


Do you forget things: 0 Not at all 2 Sometimes 4 A lot Unknown or Not Documented

Is it hard to keep up withschoolwork:


Do you miss school because of notfeeling good:


Do you miss school because youhave to go to the doctor's or

hospital:


If No, Please select a reason whythe PedsQOL was not completed:

Too sick Administrative

If Administrative: Select a specificreason:

Urgent implant, no time Coordinator too busy or forgot Unable to contact patient Other reason (specify)


The VAD noise bothers me when Iam awake:


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Always Very Often Sometimes Rarely Never

The VAD noise bothers me when Iam trying to sleep:


I have pain or discomfort at thedriveline or tubing pump exit site:


I have difficulty sleeping due to theposition of the driveline or tubing

pump exit site:


I am bothered by how I look with theVAD:


I worry about the VAD breaking ormalfunctioning:


I am bothered that I cannot visitfamily or friends outside the home

or hospital with the VAD:



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I am bothered that I cannot moveeasily from place to place with the

VAD:


I cannot participate in usual playactivities with the VAD:


I find it difficult to express feelingsand talk to others about the VAD:


Overall, I would describe my daytoday level of worry with the VAD to

be:

High Between High and Medium Medium Between Low and Medium Low

Overall, I would describe my daytoday level of happiness with the VAD

to be:


If No, Please select a reason whythe VADQoL form was not

completed:





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PedsQL

ABOUT MY HEALTH AND ACTIVITES (problems with...)



It is hard for me to walk more thanone block:

0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

It is hard for me to run: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

It is hard for me to do sports activityor exercise:


It is hard for me to lift somethingheavy:


It is hard for me to take a bath orshower by myself:



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ABOUT MY FEELINGS (problems with...)

It is hard for me to do choresaround the house:


I hurt or ache: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

Where?

I have low energy: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I feel afraid or scared: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I feel sad or blue: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I feel angry: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I have trouble sleeping: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented


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HOW I GET ALONG WITH OTHERS (problems with...)

ABOUT SCHOOL (problems with...)

I worry about what will happen tome:


I have trouble getting along withother kids:


Other kids do not want to be myfriend:


Other kids tease me: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I cannot do things other kids myage can do:


It is hard to keep up when I playwith other kids:


Is it hard to pay attention in class: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I forget things:


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VADQoL


I have trouble keeping up with myschoolwork:


I miss school because of not feelingwell:


I miss school to go to the doctor orhospital:










Always Very Often


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Sometimes Rarely Never




pump exit site:










VAD:



Always Very Often Sometimes


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Rarely Never




be:



to be:



completed:





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PedsQL

ABOUT MY HEALTH AND ACTIVITES (problems with...)



It is hard for me to walk more thanone block:


It is hard for me to run: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

It is hard for me to do sports activityor exercise:


It is hard for me to lift somethingheavy:


It is hard for me to take a bath orshower by myself:



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ABOUT MY FEELINGS (problems with...)

It is hard for me to do choresaround the house:


I hurt or ache: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

Where?

I have low energy: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I feel afraid or scared: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I feel sad or blue: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I feel angry: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I have trouble sleeping: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented


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HOW I GET ALONG WITH OTHERS (problems with...)

ABOUT SCHOOL (problems with...)

I worry about what will happen tome:


I have trouble getting along withother teens:


Other teens do not want to be myfriend:


Other teens tease me: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I cannot do things other teens myage can do:


It is hard to keep up with peers: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

Is it hard to pay attention in class: 0 Never a problem 1 Almost never a problem 2 Sometimes a problem 3 Often a problem 4 Almost always a problem Unknown or Not Documented

I forget things:


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VADQoL


I have trouble keeping up with myschoolwork:


I miss school because of not feelingwell:


I miss school to go to the doctor orhospital:










Always Very Often


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pump exit site:










VAD:





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Rarely Never




be:



to be:



completed:





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Quality Of Life (Parent)(QOL surveys cannot be administered after the visit date)

PedsQL


Did the parent complete a form? Yes No Unknown

Please select the 'Parent' form: PedsQL Toddler (24 yrs) PedsQL Young Child (57 yrs) PedsQL Child (812 yrs) PedsQL Teen (1318 yrs)

Walking: Walking more than oneblock:

0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Running: Running: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Participating in active play orexercise: Participating in sports

activity or exercise:


Lifting something heavy: Liftingsomething heavy:


Bathing: Taking a bath or shower byhim or herself:


3 Month Followup - Quality of Life Parent (2-4 yrs) version date: 12/19/2016

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Helping to pick up his or her toys:Doing chores around the house:


Having hurts or aches: Having hurtsor aches:


Low energy level: Low energy level: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Feeling afraid or scared: Feelingafraid or scared:


Feeling sad or blue: Feeling sad orblue:


Feeling angry: Feeling angry: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Trouble sleeping: Trouble sleeping: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Worrying: Worrying about what willhappen to him or her:

0 Never 1 Almost never


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2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Playing with other children: Gettingalong with other teens:


Other kids not wanting to play withhim or her: Other teens not wanting

to be his or her friend:


Getting teased by other children:Getting teased by other teens:


Not able to do things that otherchildren his or her age can do: Notable to do things that other teens

his or her age can do:


Keeping up when playing with otherchildren: Keeping up when playing

with other teens:


Paying attention in class: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Forgetting things: 0 Never 1 Almost never 2 Sometimes


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VADQoL

3 Often 4 Almost always Unknown or Not Documented

Doing the same school activities aspeers: Keeping up with schoolwork:


Missing school/daycare because ofnot feeling well: Missing school

because of not feeling well:


Missing school/daycare to go to thedoctor or hospital: Missing school

to go to the doctor or hospital:







Please select the 'Parent' form: VADQoL: Parent (child < 2 yrs) VADQoL: Parent (child >= 2 yrs)

The VAD noise bothers my childwhen he or she is awake:


The VAD noise bothers my childwhen he or she is trying to sleep:

Always Very Often


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My child has pain or discomfort atthe driveline or tubing pump exit

site:


My child has difficulty sleeping dueto the position of the driveline or

tubing pump exit site:


My child is bothered by how he orshe looks with the VAD:


My child worries about the VADbreaking or malfunctioning:


My child is bothered that he or shecannot visit family or friends

outside the home or hospital withthe VAD:


My child is bothered that he or shecannot move easily from place to

place with the VAD:


My child cannot participate in usualplay activities with the VAD:



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Rarely Never

My child finds it difficult to expressfeelings and talk to others about the

VAD:


Overall, I would describe my child'sdaytoday level of worry with the

VAD to be:


Overall, I would describe my child'sdaytoday level of happiness with

the VAD to be:



completed:





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PedsQL




Walking more than one block: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Running: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Participating in sports activity orexercise:


Lifting something heavy: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Taking a bath or shower by him orherself:



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Doing chores, like picking up his orher toys:


Having hurts or aches: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Low energy level: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Feeling afraid or scared: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Feeling sad or blue: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Feeling angry: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Trouble sleeping: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Worrying about what will happen tohim or her:



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Getting along with other children: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Other kids not wanting to be his orher friend:


Getting teased by other children: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Not able to do things that otherchildren his or her age can do:


Keeping up when playing with otherchildren:





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VADQoL


Keeping up with school activities: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Missing school because of notfeeling well:


Missing school to go to the doctoror hospital:











Always Very Often


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site:













place with the VAD:





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Rarely Never


VAD:



VAD to be:



the VAD to be:



completed:





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PedsQL












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Doing chores, like picking up his orher toys::











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Getting along with other children: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Other kids not wanting to be his orher friend:


Getting teased by other children: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Not able to do things that otherchildren his or her age can do:


Keeping up when playing with otherchildren:





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VADQoL


Keeping up with school activities: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented














Always Very Often


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site:













place with the VAD:





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Rarely Never


VAD:



VAD to be:



the VAD to be:



completed:





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PedsQL












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Doing chores around the house: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented










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Getting along with other teens: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Other teens not wanting to be his orher friend:


Getting teased by other teens: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented

Not able to do things that otherteens his or her age can do:


Keeping up when playing with otherteens:





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VADQoL


Keeping up with schoolwork: 0 Never 1 Almost never 2 Sometimes 3 Often 4 Almost always Unknown or Not Documented














Always Very Often


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site:













place with the VAD:





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Rarely Never


VAD:



VAD to be:



the VAD to be:



completed:





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Documents

3 Month Followup Pedimacs - UAB