Unfavorable Mediastinal Anatomy Yes/No Yes/No (includes sternotomies, sternal resection, radiation, flail chest, etc.) Enter # of Sternotomies: ________ Thoracic Aortic Disease Yes/No Yes/No Tracheostomy Yes/No Yes/No Plastic Bronchitis Yes/No Yes/No Nutritional/GI/Genetics: Large BMI Yes/No Yes/No Severe Diabetes Yes/No Yes/No Malnutrition/Cachexia Yes/No Yes/No History of GI Ulcers Yes/No Yes/No History of Hepatitis Yes/No Yes/No Dysfunction Yes/No Yes/No Anasarca Yes/No Yes/No Protein Losing enteropathy Yes/No Yes/No Genetic Syndrome Yes/No Yes/No (Dropdown: Muscular Dystrophy Down’s syndrome Noonan’s Other ______) Vascular issues: Heparin Induced Thrombocytopenia Yes/No Yes/No Chronic Coagulopathy Yes/No Yes/No Major Stroke Yes/No Yes/No Other Cerebrovascular Disease Yes/No Yes/No Peripheral Vascular Disease Yes/No Yes/No Oncology/infection issues: History of Organ Cancer Yes/No Yes/No History of Lymphoma, Leukemia Yes/No Yes/No History of Bone Marrow Transplant (BMT) Yes/No Yes/No History of HIV Yes/No/Unknown Yes/No (If yes, answer HIV questions below) Chronic Infectious Concerns Yes/No Yes/No Psychosocial issues: If patient is < 10 old at time of implant, based on chart review of the patient, are these conditions present or absent. Limited Cognition/Understanding Yes/No/Unknown Yes/No Limited Social Support Yes/No/Unknown Yes/No Repeated Noncompliance Yes/No/Unknown Yes/No History of Illicit Drug Use Yes/No/Unknown Yes/No History of Alcohol Yes/No/Unknown Yes/No Narcotic Dependence Yes/No/Unknown Yes/No History of Smoking Yes/No/Unknown Yes/No Currently Smoking Yes/No/Unknown Yes/No Severe Depression Yes/No/Unknown Yes/No Other Major Psychiatric Diagnosis Yes/No/Unknown Yes/No Neurological/developmental abnormalities Yes/No/Unknown Yes/No Other Comorbidity Yes/No Yes/No
Unfavorable Mediastinal Anatomy Yes/No Yes/No (includes sternotomies, sternal resection, radiation, flail chest, etc.) Enter # of Sternotomies: ________ Thoracic Aortic Disease Yes/No Yes/No Tracheostomy Yes/No Yes/No Plastic Bronchitis Yes/No Yes/No Nutritional/GI/Genetics: Large BMI Yes/No Yes/No Severe Diabetes Yes/No Yes/No Malnutrition/Cachexia Yes/No Yes/No History of GI Ulcers Yes/No Yes/No History of Hepatitis Yes/No Yes/No Dysfunction Yes/No Yes/No Anasarca Yes/No Yes/No Protein Losing enteropathy Yes/No Yes/No Genetic Syndrome Yes/No Yes/No (Dropdown: Muscular Dystrophy Down’s syndrome Noonan’s Other ______) Vascular issues: Heparin Induced Thrombocytopenia Yes/No Yes/No Chronic Coagulopathy Yes/No Yes/No Major Stroke Yes/No Yes/No Other Cerebrovascular Disease Yes/No Yes/No Peripheral Vascular Disease Yes/No Yes/No Oncology/infection issues: History of Organ Cancer Yes/No Yes/No History of Lymphoma, Leukemia Yes/No Yes/No History of Bone Marrow Transplant (BMT) Yes/No Yes/No History of HIV Yes/No/Unknown Yes/No (If yes, answer HIV questions below) Chronic Infectious Concerns Yes/No Yes/No Psychosocial issues: If patient is < 10 old at time of implant, based on chart review of the patient, are these conditions present or absent. Limited Cognition/Understanding Yes/No/Unknown Yes/No Limited Social Support Yes/No/Unknown Yes/No Repeated Noncompliance Yes/No/Unknown Yes/No History of Illicit Drug Use Yes/No/Unknown Yes/No History of Alcohol Yes/No/Unknown Yes/No Narcotic Dependence Yes/No/Unknown Yes/No History of Smoking Yes/No/Unknown Yes/No Currently Smoking Yes/No/Unknown Yes/No Severe Depression Yes/No/Unknown Yes/No Other Major Psychiatric Diagnosis Yes/No/Unknown Yes/No Neurological/developmental abnormalities Yes/No/Unknown Yes/No Other Comorbidity Yes/No Yes/No
Pedimacs_Users_Guide_v5_0_2018_03_26-1.docx