Liver - Prospective Donor Intake Form Transplant Center • = required Demographic Information First Name * (legal name) Middle Initial Last Name * Suffix (II, III, Jr., Sr.) Date of Birth * Male Female Race White Black or African American American Indian/Alaskan Native Asian Native Hawaiian or Other Pacific Islander Mid-East/Arabian Indian Sub-Continent Hispanic Unknown Mailing Address Street 1 Street 2 City State Zip Code Home Phone Number Work Phone Number Cell Phone Number Best phone number to reach you * Home Work Cell Email Address * Intended Recipient * Relationship of Recipient to You Medical History Please note that it is important that you answer these questions honestly so that an appropriate, and safe, decision can be made about your candidacy for donor evaluation. Height (in feet) * Height (in inches) * Weight (in pounds) * Allergies to Medications Current Medications (prescription and over the counter/non-prescription) with doses and frequency What surgeries have you had and approximate date for each? Do you have, or have you ever had diabetes/blood sugar problems? Yes No Are you being treated for, or do you have any history of high blood pressure? * Yes No If yes, please describe. Have you ever had a stroke or "mini-stroke"? * Yes No Do you have, or have you ever had, any heart problems? * Yes No If yes, please describe. Do you have any breathing problems? * Yes No If yes, please describe. Do you have, or have you ever had, any problems with your liver? Yes No If yes, please describe. Have you ever had any injury to your liver? Yes No If yes, please describe. Do you have any family history for liver disease? Yes No If yes, please describe. Do you drink any alcohol? Yes No If yes, please describe how much and how frequently you drink. Have you ever been told you have any type of cancer? Yes No If yes, please describe what type of cancer, treatment, and approximate dates. Is there anything else about your health that you would like to share with us? By submitting this form, you agree to our privacy policy.
