Date of physician’s Tacrolimus dose report __________
Enter the date of the tacrolimus dose report. If substitute for tacrolimus was given, enter the date of dose report for substitution. Enter the date in the DD/MMM/YYYY format.
Was Tacrolimus (Prograf, FK506) administered
Indicate if tacrolimus was administered since the previously reported reporting period.
- Yes
- No
If no, was a substitution administered
If no is selected, indicate if a substitution was administered instead of tacrolimus.
- Yes
- No
If yes, indicate substitution administered __________
If “Yes” is selected, provide the name of the medication.
Provide reason for substitution __________
Provide a reason why tacrolimus was discontinued, and a new medication was started in the text box.
Dose given _______ mg/day
Enter the dose of tacrolimus in mg/day. If a substitute for tacrolimus was given, enter dose of substitution. Enter the dose in “NNNNN” format. This format allows for five digits without a decimal.
N/A, tacrolimus discontinued ☐
If tacrolimus or the substitute was discontinued and no other substitute was administered, check this box.
Enter date of last dose __________ mg/day
Enter the last dose of tacrolimus in mg/day. If a substitute for tacrolimus was given, enter the last dose of substitution. Enter the dose in “NNNNN” format. This format allows for five digits without a decimal.
Were tacrolimus doses tapered to discontinuation
Indicate if Tacrolimus or substitute was discontinued.
- Yes
- No
- Not applicable, ongoing
If No, indicate why tacrolimus has not been or will not be discontinued
If “No” was selected, indicate a reason why tacrolimus or substitute has not or will not be discontinued.
- Tacrolimus dose reduction still in progress
- Continuation due to declining donor T-cell chimerism
- Evidence of kidney rejection reported
- Other
Specify Other__________
If “Other” was indicated, specify the reason in the text box.
CCG v.1 | CRF v.1
Post your comment on this topic.