Clinical Unknown Other, specify If specify, then complete the text box. Anticoagulant therapy at time of If anticoagulant therapy was used at the time of this event, select all therapies that apply. If Other, specify is selected, type in the specification in the block provided. Warfarin Heparin Lovenox Aspirin Dipyridamole Clopidogrel (plavix) Argatroban Bivalirudin Fondaparinux Dextran Ticlopidine Hirudin Lepirudin Ximelagatran None specify If Other, specify, then complete the text box. Please click on the link below for further instruction on administering Stroke Scales in Appendix I. Has the patient experienced a Neurological Event since time of implant? Yes, No, Unknown Note: This only applies to patients who have a CVA, TIA, or Anoxic Brain Injury. Once is selected you must complete this section for the patient’s complete STS “Yes” Intermacs® lifespan. If yes, provide 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. bedridden, incontinent and requiring constant nursing 5 Severe disability: – care and attention. 6 Dead – ST= Not Done or Not Documented OR If yes, provide NIH Stroke Scale:
Clinical Unknown Other, specify If specify, then complete the text box. Anticoagulant therapy at time of If anticoagulant therapy was used at the time of this event, select all therapies that apply. If Other, specify is selected, type in the specification in the block provided. Warfarin Heparin Lovenox Aspirin Dipyridamole Clopidogrel (plavix) Argatroban Bivalirudin Fondaparinux Dextran Ticlopidine Hirudin Lepirudin Ximelagatran None specify If Other, specify, then complete the text box. Please click on the link below for further instruction on administering Stroke Scales in Appendix I. Has the patient experienced a Neurological Event since time of implant? Yes, No, Unknown Note: This only applies to patients who have a CVA, TIA, or Anoxic Brain Injury. Once “Yes” is selected you must complete this section for the patient’s complete STS Intermacs® lifespan. If yes, provide 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 Done or Not Documented OR If yes, provide NIH Stroke Scale:
Intermacs%20Users%20Guide%20v5.0_2018_03_26.docx