Liver - Prospective Donor Intake Form
Transplant Center

= required

Demographic Information

(legal name)
(II, III, Jr., Sr.)

Mailing Address

Best phone number to reach 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.

Do you have, or have you ever had diabetes/blood sugar problems?

Are you being treated for, or do you have any history of high blood pressure? *

Have you ever had a stroke or "mini-stroke"? *

Do you have, or have you ever had, any heart problems? *

Do you have any breathing problems? *

Do you have, or have you ever had, any problems with your liver?

Have you ever had any injury to your liver?

Do you have any family history for liver disease?

Do you drink any alcohol?

Have you ever been told you have any type of cancer?

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