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Donor Info
Health Info
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Family History
Donor Information
First Name
Middle Initial
Last Name
Gender
<Select>
Male
Female
Date of Birth
Race
<Select>
American Indian/Alaska Native
Asian
Black
Declined
Multiracial/Multicultural
Unavailable
White
Address 1
Address 2
City
State
<Select>
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZipCode
Phone
Best Contact Time
Email
Emergency Contact
Contact First Name
Contact Last Name
Contact Phone
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Donor Health Information
Height
DonorHeightFeet
<Select>
1
2
3
4
5
6
7
Feet
Height
DonorHeightInches
<Select>
0
1
2
3
4
5
6
7
8
9
10
11
Inches
Weight
Lbs
Marital Status
<Select>
Never Married / Single
Married
Divorced / Separated
Widowed
Education
<Select>
Not Indicated
High School or GED
Vocational Certificate
Bachelor's Degree
Master's Degree
Doctorate or Higher
US Citizen
<Select>
Yes
No
History of Pregnancies?
<Select>
Yes
No
How Many Pregnancies?
Do You Take Birth Control or Any Hormonal Therapy?
<Select>
Yes
No
Do You Have Children?
<Select>
Yes
No
How Many Children?
Blood Type
<Select>
A
B
O
AB
Unknown
Allergies
Have You Been Vaccinated for Covid-19?
<Select>
Yes
No
Vaccine Type
<Select>
Moderna
Pfizer
J & J
Vaccine Dates
Are You On Any Prescribed Medication?
<Select>
Yes
No
Prescribed Medication
Are You On Any Over The Counter Medication?
<Select>
Yes
No
Over The Counter Medication
Employment Status
<Select>
Full-time
Part-time
Unemployed
Health Insurance Carrier
Primary Care Physician
PCP Phone
Transplant Information
Donating To
<Select>
Specific Patient on Waiting List
Anyone in Need (Anonymous)
Will You Accept Blood Transfusions?
<Select>
Yes
No
Recipient Full Name
Relationship To Recipient
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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?
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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
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