Introduction
Today M-D-Y
Last Name
* must provide value
First Name
* must provide value
Date of Birth
* must provide value
M-D-Y
View equation Gender
* must provide value
Male
Female
Other
Check all that apply.
Not Hispanic or Latino
Hispanic Cuban
Hispanic Mexican
Hispanic Puerto Rican
Hispanic Other
Specify other Hispanic ethnicity
English
Spanish
French
Arabic
Other
Single
Married
Separated
Divorced
Widowed
Children, if yes, state how many and the ages
Are you currently pregnant?
Yes
No
Yes
No
Street Address
* must provide value
State
* must provide value
Contact phone number
* must provide value
Contact phone number type
Cell
Home
Work
List Emergency Contact Name and Phone Number (two or more)
Describe any special needs (dietary, physical, other)
Weight in pounds
* must provide value
Height in feet and inches
* must provide value
example: 5 ft 8 in
Highest level of education
Grade school (0-8)
High school (9-12) or GED
Attended College/Technical School
Associate/Bachelor Degree
Post-College Graduate Degree
N/A (Less Than 5 Years Old)
Unknown
Working Full Time
Working Part Time Due to Demands of Treatment
Working Part time Due to Disability
Working Part Time Due to Insurance Conflict
Working Part Time Due to Inability to Find Full Time Work
Working Part Time Due to Patient Choice
Not Working
Retired
Would your employer provide time off to be a donor?
Yes, without pay
Yes, with pay
No
I don't know
Organ for donation
* must provide value
Kidney
Liver
Lung
A
B
AB
O
I don't know
Is there a specific person to whom you want to donate an organ?
Yes
No
Intended recipient's name
Intended recipient's date of birth
Intended recipient's relation to you
Parent Sibling Child Spouse Cousin Aunt/Uncle Non-blood relative (in-law) Friend Acquiantance I have never met this person Other
Who would provide care for you if you were a donor (someone who is not going to provide care to the recipient)?
Do you have health insurance?
Yes
No
Do you have a primary care doctor?
Yes
No
Name of primary care doctor
Primary doctors' City,State
Within last 6 months
Within last 12 months
More than 1 year ago
More than 2 years ago
Do you take any medications?
Yes
No
Provide information about your current medications below.
Daily
Two times a day
Three times a day
Other
Daily
Two times a day
Three times a day
Other
Daily
Two times a day
Three times a day
Other
Daily
Two times a day
Three times a day
Other
Daily
Two times a day
Three times a day
Other
Describe any drug allergies you have
Describe any food allergies you have
Have you ever had a mammogram?
Yes
No
Date of most recent mammogram
Today M-D-Y
Results of most recent mammogram
Normal
Abnormal
Have you ever had a pap smear?
Yes
No
Date of most recent pap smear
Today M-D-Y
Results of most recent pap smear
Normal
Abnormal
Have you ever had a PSA test?
Yes
No
Date of most recent PSA test
Today M-D-Y
Results of most recent PSA test
Normal
Abnormal
Have you ever had a colonoscopy?
Yes
No
Date of most recent colonoscopy
Today M-D-Y
Results of most recent colonoscopy
Normal
Abnormal
Have you ever had surgery?
Yes
No
Provide information about any surgical procedures below.
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Today M-D-Y
Have you ever been hospitalized?
Yes
No
Provide information about any hospitalizations below.
Today M-D-Y
Reason for hospitalization
Today M-D-Y
Reason for hospitalization
Today M-D-Y
Reason for hospitalization
Today M-D-Y
Reason for hospitalization
Today M-D-Y
Reason for hospitalization
Do you have or have you ever had any of these conditions?
Check all that apply.
Do you have or have you ever had any of these conditions?
Check all that apply.
Do you have or have you ever had any of these conditions?
Check all that apply.
Do you have any religious or moral considerations that would cause you to refuse blood products or transfusions?
Yes
No
Have you ever traveled outside the United States?
Yes
No
Provide the month/year and destination for each trip outside the United States.
Have you ever tried to donate blood and been refused for donation?
Yes
No
Provide the month/year and reason for refusal
Do you drink any alcohol?
Yes
No
Less than 4 times a month
1 time a day
1-2 times per week
3 or more times per week
Do you smoke or use smokeless tobacco?
Yes
No
Yes
No
How much did you smoke per day?
For how many years did you smoke?
Have you ever used marijuana?
Yes
No
Specify the last time you used marijuana.
Have you ever used IV drugs?
Yes
No
Specify the type of IV drug and date of last use
Have you ever used cocaine in any form?
Yes
No
Specify the last time you used cocaine.
Yes
No
Specify the type of tattoo.
Professional
Self/home
Specify the date of your last tattoo.
date_mdy
Do you have any body piercing except ears?
Yes
No
Specify the type of piercing.
Professional
Self/home
Specify the location(s) of the piercing.
Specify the date of your last piercing.
date_mdy
Do you have any history of:
Specify when you last thought of or attempted suicide
In the last 12 months
More than 12 months ago
Are you currently under the care of a mental health provider?
Yes
No
Does your family have a history of:
Check all that apply.
Specify relative(s) with hypertension
Check all that apply.
Specify relative(s) with kidney disease
Check all that apply.
Specify relative(s) with diabetes
Check all that apply.
Specify relative(s) with stroke
Check all that apply.
Specify relative(s) with heart attack/CAD
Check all that apply.
Specify relative(s) with cardiac bypass surgery
Check all that apply.
Specify relative(s) with cancer of the kidney
Check all that apply.
Specify relative(s) with other types of cancer
Check all that apply.
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