Complete form and send to BMT Coordinator 10 Days Prior to Admission, fax (03) 364 1486
Name: / NHI:
Address: / DOB:
Email:
Consultant: / Phone:
Cell:
GP Details (name and address):
SUPPORT NETWORK:
Accommodation/NTA number:
check to make sure funding covers transport and accommodation for ChCh
Recent Height: / Weight: / BSA:
Disease:
Conditioning Regime:
Cell source: / Planned Harvest Date:
All Previous Chemotherapy (including total doses of all drugs):
Previous Complications:
Smoker:
Allergies:
Significant Other Illness:
Antiemetic History:
Central Line History:
Disease status: / Date: / Test(CT scan, BM biopsy, PET):
TESTS & INVESTIGATIONS / PATIENT / DONOR (if applicable)
ABO Group:
Confirmed: Yes No / Confirmed: Yes No
RBC Antibody Screen:
HLA Antibody screen (if Allo HSCT’s):
HLA Type (if allo HSCT):
HLA Confirmatory Type (if allo HSCT):
Transfusion History: Premed required?
Refractory to platelets?
SEROLOGY / DATE / PATIENT / DONOR (if applicable)
CMV
HCV
HBV
HIV
SYPHILIS
EBV
VZV
HSV
TOXOPLASMA
VRE Screen:
CRV Screen & Nasal Swab:
Immunisation Patient & Family:
CXR and sinus CT:
ECHO/Ejection fraction:
GFR/CALCULATION:
Respiratory Function:
Pregnancy Assessment (if applicable): / (pregnancy assessmentmust be completed on all female donors (incl autologous patients) of child bearing potential within seven (7) days precedingdonor mobilisation, cell product collection or initiation of recipient’s preparative regime, whichever occurs earliest).
Dental Check:
Psychology Assessment:
Dietitian:
Pharmacist:
Audiometry(only if patient is receiving certain conditioning schedules, notably Platinum):
Old Notes Required:
Any Queries Contact: BMT Registrar (03) 364 0640, pager 8316 or BMT Coordinator (03) 364 0640 pager 8412

Ref: 5024Page 1 of 3Version 2

Authorised By: HSCT Programme Director Issued: 6THJune 2014

TOPICS TO BE DISCUSSED

(BMT Coordinator to sign & date when completed. Discussion to be documented in patient’s medical notes)

Discussed at Length D/L Discussed in Brief D/B Not Discussed N/D or N/A

DATE / SIGN / DATE / SIGN
Potential length of stay in hospital
Christchurch / Hair Loss
Wig ordered?
Tests and investigations / Changes in bowel habits
Radiotherapy / Lethargy/cognitive changes
Chemotherapy / Altered senses – taste/smell
Infection / Mucositis
Isolation / Sickness / antiemetics
Hygiene / Sexual Health
GVHD / Sexuality
Long term side effects / Fertility
Risk of relapse / Chemotherapy for conditioning
Treatment related mortality / Growth Factors
Complementary therapies / Immunosuppressants
Smoking Cessation Programme / PsychologicalAssessment
NZBS for venous access & consent / Social Services Assessment
Nutritional Assessment:
P.I. Diet Education
Total Parenteral Nutrition / Support Systems:
Travel /Accommodation assistance
Emotional Support
Additional Comments:
Date / Sign / Date / Sign
All Pre BMT Tests Complete? / Patient Info Folder given?
Wards Visited?
Consents Signed? / Ref 2973 Agreement to Medical Treatment
Ref 5027 International Registry Consent / Ref 2973 Agreement to Medical Treatment (for mobilisation chemo)(if applicable)
Ref 151F024b NZBS Processing & Storage of HPC / Trial Consent (if applicable)
Ref 107F16103 NZBS HPC Collection By Apheresis (if applicable)
ALLOGENEIC only:(record confirmation of donor availability, donor identification, donor acceptance/consent and confirmed collection date)

Ref: 5024Page 1 of 3Version 2

Authorised By: HSCT Programme Director Issued: 6THJune 2014