*************************** PERSONAL INFORMATION ******************************

Father's First and Last Name_____________________________________________________

Mother's First and Last Name_____________________________________________________

Child's First and Last Name_____________________________________________________

Address______________________________________________________________________

City_____________________________________   State________   ZIP_______________

Home Telephone  (____)___________________   Work  (____)_______________________ 

**************************** PREGNANCY AND BIRTH ***************************

Date of Birth______/______/______    Sex ___male ___female  

Weeks Gestation______   Birth Weight____lbs.____oz.   Birth Length______inches   ___Single ___Twin ___Triplet

Complications During Pregnancy_________________________________________________ 

Medications During Pregnancy____________________________________________________

Number of Total Pregnancies________     Number of other children______male ______female

*********************** DIAGNOSIS AND KASAI PROCEDURE ***************************

Age at B.A. Diagnosis________________    Age at Kasai Procedure_____________________     

Bile Flow Following Kasai    ____Good    ____Fair     ____Poor    ____Unknown    ____N/A

Gastroenterologist& Hospital_____________________________________________________

Pediatric Surgeon & Hospital____________________________________________________

Related Medical Conditions (i.e. polysplenia, heart defects,  etc.)_______________________

   _____________________________________________________________________________
   
Other Early Surgical Procedures____________________________________________________


**************************** LIVER TRANSPLANT ******************************

Number of Transplants    _____Standard Transplant    _____Living-Related Liver Transplant     

Donor  ____Child ____Adult  ____Mother  ____Father  __________________Other (specify) 

Date of  Liver Transplant(s)     1)___________________     2)________________________

                         3)___________________      4)________________________
                         
Reason(s) for Retransplantation (if applicable)_______________________________________

   _____________________________________________________________________________
   
   ___________________________________________________________________________
   
Transplant Surgeon & Hospital____________________________________________________

Transplant Surgeon & Hospital (if different)__________________________________________ 

Transplant Surgeon & Hospital (if different)__________________________________________

Current Transplant Coordinator & Hospital__________________________________________

Comments __________________________________________________________________

    ____________________________________________________________________________
    
    ____________________________________________________________________________
    
    ____________________________________________________________________________

**************************** NUTRITIONAL STATUS *********************************

Current Weight___________lbs.                 Current Weight Percentile__________%

Current Height_________ft._________inches        Current Height Percentile___________%

Special Infant Formula ____Portagen ____Pregestimil ____Alimentum _____________Other

Special Diet__________________________________________________________________

Feeding Equipment (if applicable) ____Naso-Gastric Tube  ____G-Tube ____J-Tube ____Other     

Vitamin / Nutritional  Supplements_________________________________________________

**************************** MEDICATIONS *******************************

Current Medications & Dosages
____________________________________      ____________________________________

____________________________________      ____________________________________

____________________________________      ____________________________________

____________________________________      ____________________________________

Comments___________________________________________________________________
      
**************************** UNOS INFO ********************************

UNOS Status (circle one)    1      2      3       4       7       N/A

Date Listed for Transplant______/______/______      Blood Type______________________

Transplant Center Where Listed__________________________________________________

Comments___________________________________________________________________
  
**************************** CURRENT HEALTH STATUS *************************

Please describe your child's current health and development______________________________

   ____________________________________________________________________________
   
   ____________________________________________________________________________
 
**************************** BALT SERVICES *********************************

Please check items you'd like additional information about
 ___Parent Matching                                        
 ___Twin Registry  
 ___Telephone Support Team                               
 ___Transplant Center Referral & Info 
 ___Spanish Translation of The Biliary Tree               
 ___Baby Formula & Supplies Network  
 ___Biliary Atresia & Liver Transplant Library List        
 ___Kids' Tree House Club 
 ___All past issues of The Biliary Tree ($20/15+ issues)   
 ___Volunteer Positions at BALT
 ___Organ Donors Make Better Livers Bumper Stickers ($3.35 each or 4 stickers for $10.90)
 ___Tax-Deductible Donation (please help us to continue helping families)

Please make your check or money order made payable to the Biliary Atresia & Liver Transplant Network.
  ___I authorize    (OR)
  ___I do not wish BALT to release my name, address and telephone number to 
other parents seeking support and to publish materials that I submit (pictures, letters, articles, etc.) 
in The Biliary Tree newsletter. 

Signature______________________________________ Date_____/_____/_____

PLEASE MAIL THIS QUESTIONNAIRE TO:
The Biliary Tree
3835 Richmond Ave., Box 190
Staten Island, NY  10312

 

Last modified: 11 May 2000