Medical History Condition

*Note: Report pertinent medical history conditions except End Stage Renal Disease.

Timeline requirements for this form are as follows:
Assessment timeframe: Pre-Transplant, Day 1, Day 2, Day 3, Day 4, Week 2, Week 3, Week 4, Week 5, Week 6, Week 7, Week 8, Week 10, Week 12, Month 4, Month 5, Month 6, Month 7, Month 8, Month 9, Month 10, Month 11, Month 12, Month 14, Month 16, Month 18, Month 20, Month 22, Month 24, Month 27, Month 30, Month 33, Month 36, Month 48, Month 60
Submission timeframe:

Date of report __________
Enter the date medical history was conducted. Enter the date in the DD/MMM/YYYY format.

Except for End Stage Renal Disease, does the recipient have any medical conditions to report or have any conditions been previously reported?
Indicate if there are any relevant medical conditions to report since the previous reporting period.

• Yes
• No
  

If No, save the form as complete.

If Yes, indicate medical conditions below.

Hypertension diagnosed
Indicate if hypertension was diagnosed since the previous reporting period.

• Yes
• No
  

If yes, when diagnosed
Indicate if hypertension was diagnosed before or after kidney transplantation.

• Pre-Transplant
• Post-Transplant
  

Hypertension diagnosis date __________
Enter the date hypertension was diagnosed. Enter the date in the DD/MMM/YYYY format.

Hypertension resolution date __________
Enter the date hypertension resolved. Enter the date in the DD/MMM/YYYY format.

N/A, hypertension ongoing ☐
If hypertension is ongoing, leave hypertension resolution date empty and check this box.

Medication administered If yes, report medications on Concomitant Medication Form
Indicate if medication was administered for hypertension. This includes: [add examples]

• Yes
• No
  

Diabetes mellitus diagnosed
Indicate if Diabetes mellitus was diagnosed since the previous reporting period.

• Yes
• No
  

If yes, when diagnosed
Indicate if Diabetes mellitus was diagnosed before or after kidney transplantation.

• Pre-Transplant
• Post-Transplant
  

Diabetes mellitus diagnosis date __________
Enter the date Diabetes mellitus was diagnosed. Enter the date in the DD/MMM/YYYY format.

Diabetes mellitus resolution date __________
Enter the date Diabetes mellitus resolved. Enter the date in the DD/MMM/YYYY format.

N/A, diabetes mellitus ongoing ☐
If Diabetes mellitus is ongoing, leave Diabetes mellitus resolution date empty and check this box.

Medication administered If yes, report medications on Concomitant Medication Form
Indicate if medication was administered for Diabetes mellitus. This includes: [add examples]

• Yes
• No
  

Hyperlipidemia diagnosed
Indicate if Hyperlipidemia was diagnosed since the previous reporting period.

• Yes
• No
  

If yes, when diagnosed
Indicate if Hyperlipidemia was diagnosed before or after kidney transplantation.

• Pre-Transplant
• Post-Transplant
  

Hyperlipidemia diagnosis date __________
Enter the date Hyperlipidemia was diagnosed. Enter the date in the DD/MMM/YYYY format.

Hyperlipidemia resolution date __________
Enter the date Hyperlipidemia resolved. Enter the date in the DD/MMM/YYYY format.

N/A, Hyperlipidemia ongoing ☐
If Hyperlipidemia is ongoing, leave Hyperlipidemia resolution date empty and check this box.

Medication administered If yes, report medications on Concomitant Medication Form
Indicate if medication was administered for Hyperlipidemia. This includes: [add examples]

• Yes
• No
  

Cancer diagnosed
Indicate if Cancer was diagnosed since the previous reporting period.

• Yes
• No
  

If yes, when diagnosed
Indicate if Cancer was diagnosed before or after kidney transplantation.

• Pre-Transplant
• Post-Transplant
  

Cancer diagnosis date __________
Enter the date Cancer was diagnosed. Enter the date in the DD/MMM/YYYY format.

Cancer resolution date __________
Enter the date Cancer resolved. Enter the date in the DD/MMM/YYYY format.

N/A, Cancer ongoing ☐
If Cancer is ongoing, leave Cancer resolution date empty and check this box.

Medication administered If yes, report medications on Concomitant Medication Form
Indicate if medication was administered for Cancer. This includes: [add examples]

• Yes
• No
  

Did GVHD occur or persist since last report for the study
Indicate if GVHD was diagnosed since the last reporting period

• Yes
• No
  

If yes, indicate type (if acute GVHD is reported, also complete the Acute GVHD form)
Indicate the type of GVHD that was diagnosed since the last reporting period

• Acute GVHD
• Chronic GVHD
• Overlap GVHD
  

Infection (add additional log lines if reporting more than one infection for this reporting period)

Infection diagnosed
Indicate if an infection was diagnosed since the last reporting period.

• Yes
• No
  

If yes, when diagnosed
Indicate if the infection was diagnosed pre- or post-transplant.

• Pre-Transplant
• Post-Transplant
  

If yes, type of infection
Indicate the type of infection

• Bacterial
• Viral
• Fungal
• Other, specify __________
  

Infection diagnosis date __________
Enter the date the infection was diagnosed in the DD/MMM/YYYY format. The date of diagnosis should be the date the specimen was collected.

Infection resolution date __________
Enter the date the infection resolved in the DD/MMM/YYYY format .

N/A, infection ongoing ☐
If the infection is ongoing, leave infection resolution date empty and check this box.

Medication administered If yes, report medications on Concomitant Medication Form
Indicate if medication was administered for the infection.

• Yes
• No
  

Other medical condition diagnosed
Indicate if other medical condition diagnosed since the previous reporting period.

• Yes
• No
  

If yes, when diagnosed
Indicate if other medical condition was diagnosed before or after kidney transplantation.

• Pre-Transplant
• Post-Transplant
  

Hyperlipidemia diagnosis date __________
Enter the date other medical condition was diagnosed. Enter the date in the DD/MMM/YYYY format.

Hyperlipidemia resolution date __________
Enter the date other medical condition resolved. Enter the date in the DD/MMM/YYYY format.

N/A, Hyperlipidemia ongoing ☐
If other medical condition is ongoing, leave other medical condition resolution date empty and check this box.

Medication administered If yes, report medications on Concomitant Medication Form
Indicate if medication was administered for other medical condition.

• Yes
• No
  

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