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M.D. GLOBAL MEDICAL HISTORY QUESTIONNAIRE
Providing specific answers e
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Donor Name:
*
🛈
Donor Height
*
🛈
Weight:
*
🛈
Age:
*
🛈
Gender
*
Female
Male
Form Completed By:
*
🛈
Relationship to Donor:
*
🛈
Phone Number:
*
🛈
Has the donor recently traveled to any foreign countries?
*
YES
NO
UNKNOWN
Has the donor ever been diagnosed with or tested positive for HIV, HEP C or B?
*
YES
NO
UNKNOWN
Does the Donor have Osteoarthritis or Arthritis?
*
No
Unknown
Yes - Osteoarthritis
Yes- Arthritis
List the areas (ex. leg, hand, etc)
List the areas (ex. leg, hand, etc)
Has the donor had orthopedic surgeries? (Only mark if hardware was implanted)
*
YES - L. Knee
YES - R. Knee
YES - L. Shoulder
YES - R. Shoulder
YES - L. Ankle
YES - R. Ankle
YES - Upper Spine/Back
YES - Lower Spine/Back
YES - L. Hip
YES - R. Hip
YES - L. Wrist
YES - R. Wrist
YES - L. Elbow
YES - R. Elbow
YES - Other
NO
UNKNOWN
Other (not listed)
Other (not listed)
Does the donor have: (Please check all that apply)
*
Alzheimer's
MS
Parkinson's
Dementia
Clinical Depression
Bipolar
Epilepsy
Schizophrenia
Autism
ALS
Cerebral Vascular Accident
Brain Tumor
NONE
UNKNOWN
Other (not listed)
Other (not listed)
Does the donor have a history of Cancer?
*
Yes
No
Unknown
Area of Cancer (select all that apply).
*
Not applicable
Brain
Breast
Skin
Prostate
Lung
Liver
Pancreas
Bone
Blood
Other (not listed)
Other (not listed)
How long ago?
*
🛈
Not applicable
1 yr.
2 yrs.
3 yrs.
4 yrs.
5 yrs.
6 yrs.
7 yrs.
8 yrs.
9 yrs.
10 yrs.
11 yrs.
12 yrs.
13 yrs.
14 yrs.
15 yrs.
Not Specified
Chemotherapy?
*
Not Applicable
YES
NO
Radiation?
*
Not Applicable
YES
NO
Other treatment? (if not applicable, indicate n/a).
*
Duration of treatment:
*
Not applicable
1 yr.
2 yrs.
3 yrs.
4 yrs.
5 yrs.
6 yrs.
7 yrs.
8 yrs.
9 yrs.
10 yrs.
11 yrs.
12 yrs.
13 yrs.
14 yrs.
Not specified.
Is/was the Cancer in Remission?
*
Not Applicable
YES
NO
Unkown
Does the donor have Diabetes?
*
YES
NO
Unkown
Does the donor have Kidney problems?
*
YES
NO
UNKNOWN
Does the donor have: (please check all that apply)
*
COPD
Asthma
Emphysema
Chronic Bronchitis
None
Unknown
Does the donor have: (please check all that apply)
*
Glaucoma
Cataracts
Corneal Disease
None
Unknown
Does the donor have: (please check all that apply)
*
Skin Cancer
An infection (any type)
Psoriasis
Eczema
Cellulitis
Shingles
None
Unknown
Does the donor have: (please check all that apply)
*
Heart Disease
Hypertension
Cardiac Surgery
Atherosclerosis
None
Unknown
Please check all that apply:
*
Consumes Alcohol Regularly
Uses Tobacco
Uses street drugs
Homeless
None
Unknown
What medications does/did the donor take?
*
Please add additional information or conditions not listed.
*