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Immunosuppression Screen off-line screening tool 2011 Please enter or select the correct answers and then copy these answers to the on-line tool located at http://immunosuppressionscreen.net.au Key: indicates only one one of the answers can be selected indicates that multiple answers can be selected ____ indicates that a value should be entered Question Part A Cardiovascular Risk Answers Age ______ Sex Male Female Symptomatic cardiovascular disease: Angina Check all that apply AMI (current or previous) Cardiac failure Stroke TIA Peripheral vascular disease Unsure Smoking Yes No Diabetes Yes No Current blood pressure is closest to 120/75 Total Cholesterol ______ or Not available HDL ______ or Not available Chol : HDL ratio ______ or Not available 140/85 160/95 180/105 Question Part B Infection Co-morbidities Answers HIV positive Yes No Yet to be tested Hepatitis B: HBsAg positive Yes No Yet to be tested (if answer above is “No”) Yes No Yet to be tested Hepatitis C positive Yes No Yet to be tested (if answer above is “Yes”) Hepatitis C virus cleared Which best applies Hepatitis C virus active Anti-HepB core antibody positive Hepatitis C virus activity yet to be determined Definite history of Chickenpox Yes No Yet to be tested Cytomegalovirus antibody positive Yes No Yet to be tested Tuberculosis Yes No Yet to be tested (if answer above is “Yes”) Active tuberculosis Which best applies Latent tuberculosis Tuberculosis previously treated Tuberculosis activity yet to be determined Active dental/ periodontal disease Question Yes No Yet to be tested Part C Vaccination Status Answers Influenza vaccination current Yes No Unsure Pneumococcal vaccination in previous 5 years Yes No Unsure Vaccine safety education provided Yes No Unsure Are routine vaccinations up to date Yes No Unsure Question Part D Cancer Risk Answers Previous malignancy Yes No Unsure Non-melanoma skin cancers Yes No Unsure Previous cytotoxic medication use Yes No Unsure Part E Fertility Planning Answers Question Fertility planning required Yes No Unsure Breastfeeding planning required Yes No Unsure Question Part F Corticosteroid Risk Answers Corticosteroid use in the past, current Yes or likely in the future No Bone Mineral Density result available Yes No (if answer above is “Yes”) T-score : Hip ______ Lumbar spine ______ Bone Mineral Density Do any of the following apply Prior fracture Ave dose > 15mg daily (Prednisone equivalent) Ave dose 7.5 - 15mg daily post menopausal Ave dose 7.5 - 15mg daily Average dose 7.5 - 15mg daily premenopausal 25-Vitamin D levels Normal Deficient Yet to be assessed Gastrointestinal health: Dyspepsia Check all that apply Gastro-oesophagael reflux Peptic ulcer disease Glaucoma Yes No Yet to be assessed Cataracts Yes No Yet to be assessed Steroid psychosis/agitation Yes No Unsure Current body weight ______ kg or ______ lb or Not available Current height ______ M or ______ Feet and ______ Inches or Not available Adrenal suppression education provided Yes No Unsure Please access the Immunosuppression Screening Tool located at http://immunosuppressionscreen.net.au and enter these answers to determine the resultant problems and tasks.
