LivingDonor - Home Index

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Donor Information

First Name

Middle Initial

Last Name

Gender

Date of Birth

Race

Address 1

Address 2

City

State

ZipCode

Phone

Best Contact Time

Email

Emergency Contact

Contact First Name

Contact Last Name

Contact Phone

Donor Health Information

Height

Feet

Height

Inches

Weight

Lbs

Marital Status

Education

US Citizen

History of Pregnancies?

How Many Pregnancies?

Do You Take Birth Control or Any Hormonal Therapy?

Do You Have Children?

How Many Children?

Blood Type

Allergies

Have You Been Vaccinated for Covid-19?

Vaccine Type

Vaccine Dates

Are You On Any Prescribed Medication?

Prescribed Medication

Are You On Any Over The Counter Medication?

Over The Counter Medication

Employment Status

Health Insurance Carrier

Primary Care Physician

PCP Phone

Transplant Information

Donating To

Will You Accept Blood Transfusions?

Recipient Full Name

Relationship To Recipient

Donor Medical History


Hypertension	Yes	No	Hypertension Additional Info
Diabetes	Yes	No	Diabetes Additional Info
Kidney Disease	Yes	No	Kidney Disease Additional Info
Lung Disease	Yes	No	Lung Disease Additional Info
Heart Disease	Yes	No	Heart Disease Additional Info
Gastrointestinal Problems	Yes	No	Gastrointestinal Additional Info
Autoimmune Disorders	Yes	No	Autoimmune Disorders Additional Info
Neurological Disorders	Yes	No	Neurological Disorders Additional Info
Genitourinary Issues	Yes	No	Genitourinary Additional Info
Cancer	Yes	No	Cancer Type
Blood Disorder or Blood Clot	Yes	No	Blood Disorder Additional Info
Liver Disease	Yes	No	Liver Disease Additional Info
Jaundice	Yes	No	Jaundice Additional Info
Psychiatric History	Yes	No	Psychiatric History Additional Info
History of Smoking?	Yes	No	If Yes How Long?
Do You Drink Alcohol?	Yes	No	If Yes How Many Drinks Per Week?
Do You Use Recreational Drugs?	Yes	No	If Yes What Kinds and How Frequently?
Have You Had Any Surgeries?	Yes	No	If Yes Please List:
Have You Ever Had A PAP Smear?	Yes	No	If Yes When Was Most Recent One?
Have You Ever Had A Mammogram?	Yes	No	If Yes When Was Most Recent One?
Have You Ever Had A Colonoscopy?	Yes	No	If Yes When Was Most Recent One?
Addtional Donor Medical History			DonorHistoryAdditional

Donor Tuberculosis Screening


Were You Born Outside of the US?	Yes	No	If Yes Where?
Have You Spent More Than 3 Months or Participated in Relief Work in a High Risk Country?	Yes	No	If Yes Where?
Have You Ever Resided in or Worked in Hospitals, Nursing Homes, Correctional Facilities, Other Health Care Settings or Homeless Shelter?	Yes	No	If Yes Where?
Do You Have a History of Injection Drug Use?	Yes	No	If Yes What Types?
Have You Ever Had an Abnormal Chest X-ray With Evidence of Prior Tuberculosis?	Yes	No	If Yes When?

Donor's Family Medical History


Hypertension	Yes	No	Hypertension Additional Info
Diabetes	Yes	No	Diabetes Additional Info
Kidney Disease	Yes	No	Kidney Disease Additional Info
Lung Disease	Yes	No	Lung Disease Additional Info
Heart Disease	Yes	No	Heart Disease Additional Info
Gastrointestinal Problems	Yes	No	Gastrointestinal Additional Info
Autoimmune Disorders	Yes	No	Autoimmune Disorders Additional Info
Neurological Disorders	Yes	No	Neurological Disorders Additional Info
Genitourinary Issues	Yes	No	Genitourinary Additional Info
Cancer	Yes	No	Cancer Type
Blood Disorder or Blood Clot	Yes	No	Blood Disorder Additional Info
Liver Disease	Yes	No	Liver Disease Additional Info
Jaundice	Yes	No	Jaundice Additional Info
Psychiatric History	Yes	No	Psychiatric History Additional Info
Addtional Family Medical History			FamilyHistoryAdditional