First Name* must provide value
Last Name* must provide value
Date of birth* must provide value
Today M-D-Y
SSN (this is needed to create a medical record for you)* must provide value
Gender* must provide value
Female
Male
Height in feet* must provide value
1 2 3 4 5 6 7 8
Height in inches* must provide value
0 1 2 3 4 5 6 7 8 9 10 11
Weight (lbs)* must provide value
Please enter your weight in pounds
BMI Calculated View equation
Ethnicity* must provide value
American Indian/Alaska Native Asian Black or African American Hawaiian or Other Pacific Islander White More Than One Race Unknown / Not Reported Hispanic/Latino
Citizenship* must provide value
U.S. Citizen Resident Alien Non-Resident Alien
Street* must provide value
City* must provide value
State* must provide value
AK AL AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code* must provide value
Cell phone number* must provide value
Include Area Code
Other phone number Include Area Code
E-mail
Name and Address of your Family Doctor
Donation Type: (if Kidney Donor, please use the following link: https://redcap.musc.edu/surveys/?s=DTER8M8JLM) Liver
Kidney
Intended Recipient's Name (First and Last)* must provide value
Intended Recipient's Date of Birth Today M-D-Y
Relationship to Intended Recipient
Have you ever been treated for high blood pressure? Yes
No
If yes, for how many years?
If yes, how is your blood pressure now? Good Control
Fair Control
Poor Control
Have you ever had a heart attack? Yes
No
If yes, have you had a heart attack in the last 6 months? Yes
No
How many heart bypass operations have you had?
How many heart angioplasty or stent procedures have you had?
Do you ever have chest pain when you exercise or are under stress? Yes
No
Do you ever have chest pain at other times? Yes
No
What happens when you walk up 2 flights of stairs? No problem
Shortness of breath
Chest pain
Cannot walk 2 flights
Have you had a stress test within the last year? Yes
No
If yes, where? (name and address of facility)
If yes, what did it show? No problem
Abnormal
Don't know
How many strokes have you had?
How many bypass operations have you had on your legs to improve blood flow?
Have you ever been treated for diabetes or high blood sugars? Yes
No
If yes, how many years ago were you first treated?
What treatments have you ever used to treat diabetes or high blood sugars? Diet
Pills
Insulin
When was your last physical exam?
When was your last mammogram, if applicable?
When was your last pap smear, if applicable?
When was your last colonoscopy?
When was your last PSA (prostate specific antigen) blood test, if applicable?
Please describe abnormal results from these tests, if applicable.
List the medications or foods you are allergic to, and the reaction you had when you took them:
List the medications you are taking now* must provide value
Is your mother alive? Yes
No
If alive, how old is she?
If dead, how old was she when she died?
What caused her death?
Is your father alive? Yes
No
If alive, how old is he?
If dead, how old was he when he died?
What caused his death?
How many living brothers and sisters do you have?
How many living children age 18 or older do you have?
How many living children under age 18 do you have?
How often do you currently speak with or see the recipient? Every day
Several times a week
Several times a month
Once a month
Less than once a month
Please tell us what motivated you to want to be considered as a living donor:
Your present employment status: Work full-time
Work part-time
Not working
What is your present (or past) occupation?
If you are currently employed, will you receive paid leave/income during your time off for the surgery and recovery periods? Yes
No
Your present marital status: Married
Never married
Divorced
Widowed
Your highest educational degree: Did not finish elementary school
Did not finish high school
High school diploma
College graduate
Graduate degree
Do you smoke cigarettes? Never smoked
Quit smoking
Still smoking
How many packs per day?
Do you drink alcohol? Yes
No
How many drinks per week?
Date of last use?
Do you use intravenous drugs? Never used
Quit over a year ago
Quit within past year
Still using
Which drugs?
How much and how often?
Do you use other illegal drugs? Never used
Quit over a year ago
Quit within past year
Still using
Which drugs?
How much and how often?
Have you ever been treated for substance abuse? Yes
No
Have you ever been involved in legal issues involving law enforcement (including DUI)? Yes
No
Have you ever been in prison? I was never in prison or sentenced to be in prison
I was sentenced to prison but have not served prison time
I was in prison in the past
I have a religious belief that prevents me from receiving blood products. Yes
No
Name
MRN
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