:Patient code: Contact number

Date of birth: Age :

Age at diagnosis:

Gender: Male☐ Female☐

Residency:

Race:

Occupation:

Marital status: Married ☐ Single☐ Divorced ☐

Blood Group :

Weight : Height: BMI :

Time lapse from first sign and symptoms to date of diagnosis :

Age at diagnosis:

Date of Diagnosis:

Initial signs & symptoms:

Pallor ☐ poor appetite ☐ irritability ☐ Jaundice ☐ Fatigue☐ Abdominal pain

☐ Splenomegaly ☐ abdominal fullness ☐

Initial Blood investigations:

WBC:

N. ☐ L. ☐ E. ☐ B. M.

Hb:

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Less than 5 ☐ 5-8 ☐ 8-10 > 10

MCV MCH MCHC RDW

PLT count

More than 450000☐ Less than 450000☐

Blood film :

RBC:

WBC:

PLT:

Retic count:

Coomb’s Test:

Positive ☐ Negative☐
AST ALT ALP TSB Direct TSB Ind irect TSB ALP

B.urea s.creatinine uric acid S.LDH

s.Iron S.ferritin TIBC Transferrin Saturation

TSH T3 T4 others:

Splenomegaly:

YES☐ Size:

NO☐

Hepatomegaly:

YES☐ Size

No

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Echo findings: EF:

DEXA scan:
Osteopenia:
Osteoporosis:

X-ray findings:

MRI findings:

Comorbidities;
HTN ☐ DM☐ IHD ☐ liver cirrhosis ☐ Renal impairment or failure ☐

Endocrine abnormalities:
Thyroid: Pituitary: Growth: Estrogen:
Testosterone: Androgen: LH: FSH:

Development & intellectual Problem:

Social & Psychological difficulties:

Type of supportive care:

Packed RBC transfusion numbers:

Iron Chelation:

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Deferoxamine: Deferiprone: Deferasrox:

Side effects of Iron chelation therapy:

Ototoxicity: ophthalmotoxicity: Joint pain:
Infection:
Duration of Iron chelation therapy:
Last ferritin level:
Hepatic Cirrhosis score:
Age at allogenic BM transplantation:
Type of allotransplant:
Fully matched Haploidentical degree of donor /recipient match:

Type of myeloablative conditioning:

Total body irradiation:

Time to engraftment: Hb recovery time: neutrophil recovery

time: Platelet recovery time:

Post-transplant complications:
Infection: Bacterial: Viral: Fungal:

VOD :
Acute GVHD: grade of Skin GVHD: grade of hepatic GVHD:
Grade of GIT GVHD Grade of marrow GVHD: Other:

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Chronic GVHD: Skin: Hepatic: GIT:
Other:

Type of post-transplant immunosuppressant drugs:

Period of transfusion independent from transplant:

Failure of allogenic transplant:

Cause of death after transplant:

Overall survival from transplant date:

Performance Status after transplant:

Quality of life of post-transplant period:

Social & Psychological wellbeing of post-transplant period:

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