Post-splenectomy care check list

Please retain original copy (revised July 2011)
PATIENT’S HOSPITAL STICKER or complete by hand
REGISTRATION FORM – fax to 03 9076 2431
Hospital record number ….…….……………
Victorian Spleen Registry (VSR) based at The Alfred hospital
Full name ……….………………………………. 2nd Floor Burnet Building, 85 Commercial Road, Melbourne 3004 Address .………………….…………………….
Suburb & postcode…….…….……………….…… State ……. Home phone ……….…….……
2. Medicare No:
MUST BE COMPLETED
3. Indication for referral

Patient’s Mobile………………………….………….
Patient’s Email …………………….………….…….
Contact number of person NOT LIVING WITH
4. Date of splenectomy
PATIENT (can be a friend or relative)
5. Reason for splenectomy
Second contact ph. …………….….…………. Trauma (describe) …….……………
Name at second no …….………….….……. Haem disorder (specify) …………
Cancer (specify) …………….…….
Other …………………………………………….…………….… 6. Surgeon’s name:…………………………. 6a. Hospital where splenectomy performed …………………….………
7. Allergic to any antibiotics?
no if YES, which antibiotic ………….………………….

8. Allergic to any vaccines?
no if YES, which vaccine …………….………………….
9. Vaccination administered
Past history of ever having
***Refer to recommendations for details of
Date last received
received this vaccine?
vaccination schedule before administering***
If yes please state date or year –
Pneumococcal conjugate
(eg. Prevenar 7, Synflorix 10, Prevenar 13)
Pneumococcal polysaccharide
(eg. Pneumovax 23)
Meningococcal C conjugate
(eg. Menjugate, Meningitec, NeisVac-C)
Meningococcal polysaccharide
(eg. Mencevax ACWY)
Meningococcal ACWY conjugate
(eg. Menveo)
Haemophilus influenzae type b
(eg. Liquid Pedvax or Hiberix)
Influenza Vaccine
(annual -administered March to end of flu season)
What was prescribed?
10. Prophylactic Antibiotics
Other (please specify) …………………………. mg FREQUENCY
times per day
DURATION recommended?
11. Emergency supply of
What was prescribed?
antibiotics (eg. Amoxil 3gm dose)
Other (please specify) ………………….…………. patient to seek medical attention after taking STAT DOSE
12. Has patient received an
Education session (  risk of infection)
13. Since splenectomy has there been
GP Name……………………………………Address………………………………………………Email………………………………. Suburb … …………………………. Postcode State ………… Phone number ………………………………. Has this patient been informed that their information will be forwarded to the Vic Spleen Registry
Additional information………………………………………………………………………………………….……………………………. PRINT name of person filling in this form………………………………………phone no/pager …………….….……
Any queries please call VSR office (03) 9076 3 The VSR is supported by & Department of Health, Vic &

Source: https://spleen.org.au/VSR/Files/Spleen_Registry_Registration_Form.pdf