Living Donor Online Referral
Basic Demographics
Name (Legal):
Date of Birth:
Height:
Weight:
Assigned Gender:
Male
Female
Donor Info
Do you wish to donate to:
Someone Specific
Anyone in Need
If someone specific, name of the person you would like to donate to:
Is the intended recipient a patient at LVHN Transplant?
Yes
No
Not Sure
What is your relationship with the intended recipient?
Sibling
Parent
Child
Aunt/Uncle
Cousin
Spouse
Mother/Father in law
Brother/Sister in law
Son/ Daughter in law
Friend
Social Media
Other
If relationship is other, please specify:
Have you ever used LVHN services?
Yes
No
Health Questions
Do you have any religious beliefs that might prevent you from receiving a blood transfusion?
Yes
No
Do you have any allergies to food or medications?
Yes
No
If yes, please list:
Do you have a history of asthma?
Yes
No
Have you ever been diagnosed with diabetes?
Yes
No
Do you have a family history of diabetes (parents, siblings or grandparents)?
Yes
No
Do you have high blood pressure?
Yes
No
Have you ever been diagnosed with kidney stones?
Yes
No
If yes, when?
Do you have a history of cancer?
Yes
No
If yes, when?
If yes, what was your treatment (surgery, radiation, chemotherapy)?
Do you take any prescribed medications?
Yes
No
If yes, please list, including dosages and frequency:
Have you had abdominal surgery?
Yes
No
If yes, please list procedure and date of procedure:
Have you ever been pregnant?
Yes
No
N/A
If yes, did you have Gestational Hypertension?
Yes
No
If yes, did you have Gestational Diabetes?
Yes
No
If yes, did you have Preeclampsia?
Yes
No
If yes, did you have Eclampsia?
Yes
No
Have you ever had a colonoscopy?
Yes
No
If yes, when date of most recent?
Have you ever had a mammogram?
Yes
No
N/A
If yes, when was date of most recent?
Have you ever had a Pap smear?
Yes
No
N/A
If yes, when was date of most recent?
Have you ever been diagnosed with COVID-19?
Yes
No
Have you ever been diagnosed with heart disease?
Yes
No
Have you ever been diagnosed with a psychiatric diagnosis or been hospitalized for psychiatric reasons?
Yes
No
If yes, please explain:
Do you smoke cigarettes, vape, or use smokeless tobacco, now or in the past?
Yes
No
If yes, please specify which form:
If yes, when did you start?
If yes, how much do you/did you smoke?
When did you quit, if applicable?
Do you use recreational drugs, including marijuana, now or in the past?
Yes
No
If yes, what drug(s) have you or do you use?
If yes, when did you start?
If yes, how much do you/did you use?
If yes, have you ever been to any treatment, rehab, or detox for drug or alcohol use?
When did you quit, if applicable?
Do you drink alcohol, now or in the past?
Yes
No
If yes, how many drinks do you have on average per week?
If yes, how often do you have 6 or more drinks on one occasion?
Additional Demographics
Phone:
Social Security Number:
Email Address:
Address:
City:
State:
Zip Code:
Okay to mail to your address?
Yes
No
Mailing Address (if different from above):
