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Referral Checklists for:

• Lung Transplant
• Cystic Fibrosis
• Interstitial Lung Disease

Transplant Referral Checklist

Suggested Information to include in referral to the Stanford Heart-Lung and Lung Transplant Program:

1. Demographic information to include phone, address, and Social Security Number
2. Insurance information
3. History and Physical, clinic notes, or hospital discharge summary
4. Pulmonary function studies
5. X-ray report
6. Thoracic CT scan report if performed
7. Chemistry panel
8. Hematology panel
9. Sputum cultures and sensitivities for patients with cystic fibrosis or bronchiectasis
10. Copy(s) of heart catheterization report(s) if performed

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Cystic Fibrosis Referral Checklist

Suggested Information to include in referral to the Stanford Adult Cystic Fibrosis Program:

1. History and physical notes, including clinic or office notes and current medications

2. Hospital discharge if in last two years

3. Recent PFT or spirometry

4. Recent Sputum cultures and sensitivities

5. Recent CT scan

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Interstitial Lung Disease Referral Checklist

Suggested Information to include in referral to the Stanford Interstitial Lung Disease Program:

1. Most recent Pulmonary Function Tests (breathing tests)
   
2. The actual CD of recent High Resolution CT Scan of the Chest
   
3. Any Lung Biopsy Reports along with the actual slides
   
4. Recent Lab Work, including any serology testing done to identify autoimmune disease
   
5. Recent History and Physical notes
   
6. Echocardiogram
   
7. Current List of Medications
   
8. Discharge Summary from any recent hospitalizations
9. Sall recent CTs on the CD if you have had more than one.
   
10. "Six Minute Walk" or other oxygen exercise testing
    
11. Office Visit and History notes from local pulmonologist or primary care physician

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