Medical History Questionnaire
THE HARMONIZATION OF ASSESSMENT AND ACCEPTANCE CRITERIA
FOR LIVING KIDNEY DONORS PARTICIPATING IN THE CANADIAN TRANSPLANT REGISTRY –
LIVING DONOR PAIRED EXCHANGE
MEDICAL HISTORY
Sub-Sections:
1. Medical History Questionnaire
(Page 2)
This report was informed by discussions and consensus reached at the April 11-12, 2013
Workshop on the Harmonization of Living Donor Assessment and Acceptance Criteria.
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June 19, 2013
Red inserts reference Health Canada Regulations, CAN/CSA Standards, and Forum Recommendations
Medical History Questionnaire
MEDICAL HISTORY QUESTIONNAIRE
Completion of the Medical History questionnaire is a regulation requirement of the Canadian Standards
Association and Health Canada (CAN/CSA-Z900.2.3-12).
 The questionnaire must be filled out by the potential living kidney donor candidate and then reviewed
with the candidate in person, by a donation team clinician. This may be a nurse practitioner, registered
nurse coordinator, physician or physician assistant.
 The donation team clinicians may determine if additional questions are required on a case by case
basis depending on the candidate’s initial response.
 Failure to complete the questionnaire will exclude an individual proceeding with the clinical
assessment for living donation.
 It is recognized that the Medical History Questionnaire is lengthy and inclusive. Programs may choose
to pre-screen candidates with an abbreviated “Screening Medical History Questionnaire” recognizing
that such a questionnaire would not be acceptable as a final document.
[Note: The final questionnaire will be assessed to ensure appropriate literacy level and will be translated into
both official languages and others as deemed necessary.]
References
A. Health Canada Regulations: Safety of Human Cells, Tissues and Organs for Transplantation
Regulations of the Food and Drug Act.
B. Guidance Document for Cell, Tissue and Organ Establishments Safety of Human Cells,
Tissues and Organs for Transplantation; Health Products and Food Branch Guidance
Document
C. Canadian Standards Association: CAN/CSA-Z900.2.3-12; CAN/CSA-Z900.1-12,
D. Enhancing Living Donation (ELD): A Canadian Forum (2006)
E. A Report of the Amsterdam Forum on the Care of the Live Kidney Donor- Data and Medical
Guidelines, Transplantation, Volume 79, Number 2S, March 27, 2006
F. Revised Preventative Measures to Reduce the Possible Risk of Transmission of CreutzfeldtJakob Disease (CJD) and Variant Creutzfeldt-Jakob Disease (vCJD) by Blood and Blood
Products, FDA, January 2002
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June 19, 2013
Red inserts reference Health Canada Regulations, CAN/CSA Standards, and Forum Recommendations
Medical History Questionnaire
Dear Potential Donor:
Thank you for coming forward to be assessed for donation. To ensure this will be safe for both you and the
person you would like to donate to, we need to ask questions about your current and past health. If we feel
that donating a kidney will create a significant short term or long term danger to your health or wellbeing we
will not consider you as a donor. To assist us in this decision, you will be required to have a physical
examination and a number of blood, urine, X-Ray and other tests as necessary to make sure that donating a
kidney would not result in unexpected health concerns.
Transplantation involves a potential risk of disease transmission from the donor to the recipient (i.e. infections
such as HIV, hepatitis, West Nile virus, and diseases such as cancer). Therefore, a screening process is
performed for all potential organ donors. This screening process includes obtaining information about you and
your family members’ past and current health by completing the attached medical history questionnaire. This
is a mandatory requirement of Health Canada for all donors of cells, tissues and organs. You will find that a
number of the questions in this questionnaire are similar to those asked when donating blood.
A negative blood test does not guarantee that a person is free of infection such as HIV and hepatitis. This is
because there may be a period of time between acquiring the infection and medical tests being able to detect
the infection. Therefore, we also need to ask some questions about personal activities including sexual
practices and lifestyle choices that are associated with the spread of these diseases.
Please be assured that all information is confidential and is used only to assess your suitability as a donor. No
information will be discussed with the potential recipient unless your permission has been obtained.
Please answer all of the questions to the best of your knowledge. If you have any questions or concerns,
please feel free to contact me. Once the nurses and doctors in our program have reviewed your responses in
the questionnaire we will be in contact with you as to what the next steps will be.
Yours Sincerely,
Donor Nurse / Clinical Coordinator
Living Donor Kidney Program
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June 19, 2013
Red inserts reference Health Canada Regulations, CAN/CSA Standards, and Forum Recommendations
*First Name (Legal):
*Middle Name (Legal):
Preferred Name:
*Surname (Legal):
*Birthdate: ……. /………../………
(Day) (Month)
Written Language:
Spoken Language:
*AGE……….
(Year)
Personal Health Insurance No. / Care Card No.:
Other Health Coverage Plan:
Health Insurance Expiry Date:
Email address:
If you have not previously provided the following information, please complete the section below:
Home Address:……………………….................................................................................................................................
……………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………
Home phone number:
Cell phone number:
Work phone number:
Fax number:
Family Doctor Name: ……………………………………….………………………
Address: ………………………………………………………………………………………………
……………………………………………………………………………………………………………
Telephone: ………………………….............
Fax: ………………………………………..
Closest laboratory for blood and urine tests:
Have you completed a personal directive, living will or enduring power of attorney?
Are you willing to travel outside the city or province for donation?
*CAN/CSA-Z900.2.3-12; Section20
PLEASE COMPLETE IN INK – Do not use Pencil. Please Answer All Questions.
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*Height
*Weight
*Sex
Male 
*Race
Female 
SECTION1. DONATION INFORMATION
1. 11.1 Do you have an intended recipient?
.
1.1.1 If yes, what is the name? …………………………………………………
1.1.2 What is your relationship to the intended recipient (please be specific)?
………………………………………………………………………………………………..
1.1.3 Have you discussed your wish to donate with the intended recipient?
1.2 Have you discussed your wish to donate with your family / friends?
1.2.1 If no, to 1.1.3 & 1.2, explain: ………………………………………………………………
…………………………………………………………………………………………………………………….
2.
 Yes  No
 Yes  No
 Yes  No
2.1 How did you hear about the Living Donor Program?
 Patient Education Session
 Recipient
 Physician
 Media (e.g., Newspaper, Internet)
 Other (please describe): ………………………………………………………………………………………...…………
3. 33.1 Have you previously been assessed for living cell/organ/tissue donation?
 Yes  No
.
3.1.1 If yes, where were you assessed……………………………………… and
when………/………/..…….
Day/Month/Year
3.2 Did you donate cells/organ/tissue?
3.2.1 If yes, what did you donate? …………………………………………………
3.2.2 If no, explain why you did not donate: …………………………………………….
…………………………………………………………………………………………………………
 Yes  No
CAN/CSA –Z900.1-12; Section 14.2.4
SECTION 2: YOUR GENERAL HEALTH
4.
4.1 Please describe your health? ….........................................................................................
…………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………..…
5.
5.1 Do you see your family doctor or a specialist for any health concerns?
5.1.1 If yes provide details:
Name of family doctor or specialist:………………………………………..
Purpose of the visit:…………………………..
Date last seen: ……/………/……….
6.
 Yes  No
7.
6.1 Do you have allergies (e.g. react to bee stings, shellfish, peanuts, medications) *
6.1.1 If yes, please describe the allergy and what happens when you have a
reaction: ………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………
7.1 Have you ever used alternative medical treatment – acupuncture/herbal remedies?
8.
8.1 Are you able to walk up 2 flights of stairs without chest pain or shortness of breath?
 Yes  No
9.
9.1 Are you physically active?
9.1.1 If yes, please explain what activities you do: ……………………………………….
……………………………………………………………………………………………………………………….
 Yes  No
 Yes  No
Day /Month/ Year
 Yes  No
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10. 10.1 Do you take any prescription medications? *
10.1.1 If yes, list all medications you take and why you take them?
………………………………………………………………..……………………………………………………….
………………………………………………………………………………………………………..………………….….
…………………………………………………………………………………………………………………………….……
…………………………………………………………………………………………………………………………………
 Yes  No
SECTION 3: YOUR HOSPITALIZATIONS, OPERATIONS & SURGICAL PROCEDURES
11. 811.1 Have you ever been in hospital or had any operations or surgical procedures such
. as biopsy’s, or scope in your stomach or colon (colonoscopy), pacemaker or implant? *
8.1.1 If yes, please describe the reason for admission. Provide date of admission
and name of specialist or surgeon (if known).
Date
Hospital
Surgeon/
Specialist
 Yes  No
Reason for Admission
CAN/CSA-2900 2.3-12 ; Section 20
12. 912.1 Have you had any operations where cells, tissue, or organs from animals (Xeno)  Yes  No
. were used, such as dental surgery or heart valve surgery where Bovine (cow) or porcine
(pig) products were used?
12.1.1 If yes, when and what type of graft? ………………………………………………….
13. 13.1 Have you ever received an organ or tissue transplant (i.e. bone, cornea, skin, heart,  Yes  No
kidney, bone marrow)?
13.1.1 If yes, what and when? …………………………………………….
14. 14.1 Have you ever had a graft or transplant of dura-mater (brain/spinal) tissue?
 Yes  No
CAN/CSA - Z900.1-12; Section 13.1.3(e)
15. 15.1 Have you ever received blood transfusions or other blood products?
15.1.1 If yes, why and when? ...........................................................................
15.1.2 If yes, were any of the blood products from the UK/ Europe since 1980?
 Yes  No
 Yes  No
FDA 2002, CAN/CSA –Z900.2.3-12; Section 12 .2.2.3 (b)
16. 16.1 Have you had a negative/adverse reaction to anesthesia?
 Yes  No
SECTION 4: YOUR PRESENT AND PAST ILLNESSES
17. 17.1 Have you had any health problems with your thyroid?
17.1.1 If yes, describe: ……………………………………………………………………………….
18. 18.1 Have you ever been tested for chest pain, heart disease or stroke?
18.1.1 If yes, please explain: …………………………………………………….
……………………………………………………………………….…………………………
…………..........….………………………………………….....………………………….
 Yes  No
 Yes  No
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19. 19.1 Do you have high blood pressure?
If yes, please answer the following questions:
19.1.1 Do you take blood pressure medication?
19.1.2 What medication do you take?
Drug name / Dose…………………….………………………………………………………………
…………………………………………….……………………………………………………………………
……………………………………………….…………………………………………………..……………
………………………………………………………………………………………………………………….
19.1.3 How long have you been on this medication? …………………
19.1.4 Did the doctor suggest any changes to your lifestyle to help?
19.1.5 If Yes describe: ………………………………………………………………………
…………………………………………………………………………………………..…………….
 Yes  No
 Yes  No
 Yes  No
Vancouver Forum 2006, CAN/CSA 2900.2.3.12; Section 13.2
20. 20.1 Do you have diabetes?
If yes, please answer the following questions:
20.1.1 Are you diet controlled?
20.1.2 Are you taking oral medication?
20.2.3 If yes, what is the name of the medication are you taking?
……………………………………………………………………………………………………………
20.1.4 How long have you been taking it for? …...............
20.1.5 Are you taking insulin injections?
20.1.6 Have you ever been treated with Injected bovine insulin? (At any
time since 1980?)
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
FDA 2002, Vancouver Forum 2006
21. 21.1 Have you ever been told you have any type of cancer (including tumor,
carcinoma, melanoma, leukemia and lymphoma, skin cancer)?
21.1.1 If yes, when and what type?
…………………………………………………………………………………………………….………………..
………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………….
21.1.2 How were you treated? Surgery Chemotherapy Radiation
 Yes  No
CAN/CSA- Z900.2.3-12; Section 12.2.2.3
22. 22.1 Have you ever had breathing problems such as asthma, emphysema, and sleep  Yes  No
apnea?
22.1.1 If yes, provide details. …………………………………………………………………
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………….
23. 23.1 Have you ever had or been diagnosed with bleeding problems or blood clots  Yes  No
(venous thrombosis, pulmonary embolism, internal blood clots, miscarriages
associated with a coagulation disorder, excessive bruising ,prolonged bleeding after
teeth extraction, or nosebleeds)?
23.1.1 If yes, explain: …………………………………………………………………………..
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
24. 24.1 Do you have a history of poor circulation, particularly in the lower legs such as,  Yes  No
leg ulcers, swelling and redness or been treated for blood clots in the leg or varicose
veins?
24.1.1 If yes, please describe: ……………………………………………………………..
……………………………………………………………………………………………………..
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25. 25.1 Have you ever been tested for liver disease or jaundice?
25.2 Do you have any history of jaundice (yellow discoloration of skin or eyes)?
25.2.1 If yes, to any of the above, please provide details: …………………….
……………………………………………………………………………………………………
…………………………………………………………………………………………………….
26. 26.1 Have you ever been tested for stomach or bowel problems such as Crohn’s
disease diverticulitis, blood in your faeces, or colitis?
26.1.1 If yes, provide details: ………………………………………………………………..
…………………………………………………………………………………………………………..
……………………………………………………………………………………………………………….
 Yes  No
 Yes  No
 Yes  No
27. 27.1 Have you been investigated for any neurological or brain diseases, such as  Yes  No
strokes, dementia, epilepsy, Alzheimer’s, brain tumors, or Parkinson’s disease?
27.1.1 If yes, what and when? .........................................................................
CAN/CSA- Z900.1-12; Section 13.1.3 (g)
28. 28.1 Have you recently experienced any of the following:
a. Memory loss or ever had seizures
 Yes
b. Periods of confusion
 Yes
c. Sudden unexplained anxiety or personality changes
 Yes
d. Visual changes
 Yes
e. Hallucinations
 Yes
f. Spontaneous rippling or twitching of parts of a muscle without full muscle  Yes
contraction (Myoclonus)
g. Unsteadiness when walking (ataxia)
 Yes
h. Speech problems (aphasia)
 Yes






No
No
No
No
No
No
 No
 No
CAN/CSA-Z900.1-12 Sections 13.1.3 (c)
29. 29.1 Have you ever had:
a. Subacute sclerosing panencephalitis
b. Progressive multifocal leukoencephalopathy
 Yes  No
 Yes  No
CAN/CSA- Z900.1-12; Section 13.1.3 (f)
30. 30.1 Have you suffered from:
a. Encephalitis (of viral or unknown origin)
b. Meningitis (of viral or unknown origin)
c. Degenerative neurologic disorder (of viral or unknown origin)
30.1.1 If the disease is currently active, have you had any symptoms within the
last month? If yes, explain: …………………………………………………………………………..
…………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………..
 Yes  No
 Yes  No
 Yes  No
 Yes  No
CAN/CSA- Z900. 1-12; Section 13.1.3 (f)
31. 31.1 Have you ever been diagnosed or investigated for an autoimmune disease (e.g.,
Lupus, Crohn’s, Rheumatoid Arthritis, Celiac, and Cushing’s Syndrome) or chronic
degenerative disease?
 Yes  No
31.1.1 If yes, please explain
CAN/CSA-Z900.1-12; Section 13.1.3
32. 32.1 Have you ever been diagnosed with or treated for a mental/ psychiatric/
emotional disorder?
 Yes  No
32.1.1 If yes, for what? …………………………………………………………………
32.1.2 When and how long?...............................................................
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33. 33.1 In the past 5 years have you ever been prescribed anti-depressants, antianxiety, pain medications, uppers/downers, or other similar medications by a  Yes  No
physician?
SECTION 5: YOUR KIDNEY HEALTH AND KIDNEY RELATED ILLNESSES
34. 34.1 Have you ever had kidney stones?
If yes, please answer the following questions:
34.1.1 When did you have kidney stones? …………………………………..
34.1.2 What treatment did you have? …………………………………………
……………………………………………………………………………………………………..
35. 35.1 Have you ever been tested for kidney disease?
35.1.1 If yes, provide details including previous dialysis requirement.
…………………………………………….……….....……………………………………………………….
…………………………………………………………………………………………………………………
36. 36.1 Have you ever had a bladder or kidney infection?
36.1.1 If yes, provide details. …………………………………………………………………
……………………………………………………………………………………………………………
………………………………………………………………………………………………………………
 Yes  No
 Yes  No
 Yes  No
SECTION 6: YOUR FAMILY’S HEALTH
37. 37.1 Does anyone in your family (parents, brothers or sisters) have diabetes?
37.1 If yes, describe: …………………………………………………………………………….
……………………………………………………………………………………………………….
………………………………………………………………………………………………………………..
 Yes  No
38. 38.1 Do you know if any of your family has had kidney stones?
 Yes  No
38.1.1 If yes, explain who: ……………………………………………………………..
………………………………………………………………………………………………
39. 39.1 Does anyone in your family have a history of any health issues such as: heart  Yes  No
disease, diabetes, cancer, strokes, bleeding problems, kidney disease, or TB?
39.1.1 If yes, please describe the health issues: ……………………………………….
…………………………………………………………………………………………………………
………………………………………………………………………………………………………….
40. 40.1 Is there any family history of liver disease?
 Yes  No
41. 41.1 Do you have any siblings?
41.1.1 If yes, please list:
 Yes  No
Gender of
siblings
M/F
M/F
M/F
M/F
M/F
Age
Health
SECTION 7: YOUR RISK OF HAVING AN INFECTION OR AT RISK OF DEVELOPING AN INFECTION/ ILLNESS
42. 42.1 Have you been vaccinated or received an injection (needle) for any reason in  Yes  No
the last 8 weeks?
42.1.1 If yes, what was the vaccination/injection? …………………………….
42.1.2 Why did you need to have the vaccination/injection? ………………
…………………………………………………………………………………………………………………
Vancouver Forum 2006
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43. 43.1 Do you currently have any infections; bacterial, fungal or viral?
43.1.1 If yes, explain:…………………………………………………………………………
……………………………………………………………………………………………………………
 Yes  No
CAN/CSA-Z900.2.3-12; Section 12.2.2.3 (a)
44. 44.1 Have you ever had a positive skin test for TB (tuberculosis)?
 Yes  No
Amsterdam Forum
45. 45.1 Have you ever received treatment for TB?
 Yes  No
CAN/CSA-Z900.2.3-12; Section 12.2.2.3 (a)
 Yes  No
46.1 Have you worked or lived on an aboriginal reservation?
47. 47.1 Have you ever been vaccinated (received shots or injections) for Hepatitis A or  Yes  No
B?
48. 48.1 Have you ever been told you have any type of hepatitis?
 Yes  No
48.1.1 If yes, what type and when? .............................................................
46.
Vancouver Forum 2006, CAN/CSA–Z900.2.3-12; Section 12.2.2.3 (a)
49. 49.1 In the past 12 months have you had close contact with another person who has  Yes  No
viral hepatitis (e.g., living in the same house and sharing kitchen and bathroom
facilities)?
CAN/CSA- Z900.1-12; Annex E. 1H
50. Have you recently experienced any of the following:
50.1 Unexplained weakness or fatigue
 Yes  No
50.2 Flu-like symptoms such as cough, cold, shortness of breath, swollen lymph  Yes  No
node, nausea, vomiting, persistent diarrhea, night sweats or fever greater then
100.5 oF (38.1 oC)?
51. 51.1 Have you or any of your family (grandparents, parents, aunts or uncles,  Yes  No
brothers or sisters) ever been diagnosed or investigated for Creutzfeld-Jakob disease
(CJD) (Mad-Cow)?
CAN/CSA-Z900.1-12; Section 13.1.3 (c)
52. 52.1 Between the years 1980 and 1996 did you spend 3 or more months in the UK  Yes  No
[England, Northern Ireland, Scotland, Wales, Isles of Man, or Channel Islands,
including Gibraltar, and the Falkland Islands]?
52.1.1 If yes, where, when and for how long? ……………………………………..
FDA 2002
53. 53.1 Since 1980 did you spend 5 or more years in Western Europe (France, Belgium,  Yes  No
Luxembourg, Spain, Germany, Italy, Switzerland, Republic of Ireland, Netherlands,
Austria, Lichtenstein, Portugal or Denmark)?
53.1.1 If yes, where and when? ............................................................
FDA 2002
54. 54.1 Have you or a sexual partner ever received intravenous treatment for  Yes  No
hemophilia or other blood disorders?
54.1.1 If Yes, have you ever received human-derived clotting factors?
 Yes  No
54.1.2 if yes, what and when? …………………………………………………
CAN/CSA –Z900.2.3-12; Section 12.2.2.3 (b)
55. 55.1 Have you ever been refused as a blood donor or asked not to donate?
 Yes  No
55.1.1 If yes, why? …………………………………………………………………………..
…………………………………………………………………………………………………….…………
56. 56.1 Did you ever receive human-derived pituitary HGH (i.e., human growth  Yes  No
hormone injections) in Canada or the US prior to 1986 or ever in any other country
to make you taller?
56.1.1 If yes, what and when? .......................................................
CAN/CSA-Z900.1-12; Section 13.1.3 (d)
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57. 57.1 In the past 12 months have you had a tattoo, ear/body piercing, acupuncture,
or electrolysis?
57.1.1 Were sterile procedures used
57.1.2 Were the instruments or ink contaminated?
 Yes  No
 Yes  No
Do not know
 Yes  No
Do not know
57.1.3 If yes, please explain: …..........................................……………………..
57.1.4 What is the name and address of the establishment:
………………………………………………….………………………………………………..
CAN/CSA- Z900.1-12; Annex E.1 (g)
58. 58.1 In the past 5 years have you traveled or lived outside Canada (except the U.S.)?
58.1.1 If yes, where and when did you travel to?
………………………………………………………………………………………………………….
Where
Year
 Yes  No
Time of year
………………………………………………………………………………………………………….
Where
Year
Time of year
………………………………………………………………………………………………………….
Where
Year
Time of year
………………………………………………………………………………………………………….
Where
Year
Time of year
CAN/CSA –Z900.2.3-12 Section 12.2.2.3 (g) [Note 6mths]
59. 59.1 Do you have you a history of travel to any areas where SARS occurred (e.g.,  Yes  No
Toronto, China, Hong Kong, etc.)?
59.2 Have you ever been diagnosed with SARS or been in contact with anyone
suspected of having SARS?
60. 60.1 Within the last 3 years, where have you traveled in Canada or the US
 Yes  No
60.1.1 If yes, what time of the year did you travel (winter, spring, summer,
and fall)?
………………………………………………………………………………………………………….
Where
Year
Time of year
………………………………………………………………………………………………………….
Where
Year
Time of year
………………………………………………………………………………………………………….
Where
Year
Time of year
………………………………………………………………………………………………………….
Where
Year
Time of year
. ………………………………………………………………………………………………………….
Where
Year
Time of year
61. 61.1 Do you have you a history of travel to any areas where SARS occurred (e.g.,
Toronto, China, Hong Kong, etc.)?
 Yes  No
61.2 Have you ever been diagnosed with SARS or been in contact with anyone
suspected of having SARS?
 Yes  No
62. 62.1Have you ever had malaria?
 Yes  No
63. 63.1 Have you ever taken anti-malarial drugs?
 Yes  No
63.1.1 If yes, when? ..........................................................................................
64. 64.1Have you ever had long term residence (>3 years) in rural Central or South
America, Mexico, or the Caribbean?
 Yes  No
64.1.1 If yes, where and when? …………………………………………………………
Amsterdam Forum
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65. 65.1 Have you ever been diagnosed with Chaga's disease, Babesiosis, or
Leishmaniasis?
 Yes  No
65.1.1 If yes, please describe: ……………………………………………………………
Amsterdam Forum
66. 66.1 In the past year have you lived in, or travelled to Africa?
 Yes  No
66.2 In the past year have you had any sexual contact with a person who lived in
Africa?
 Yes  No
67. 67.1 In the last year, have you had any swollen lymph nodes, palpable masses or
blue or purple spots on the skin or mucous membranes (suggestive of Kaposi’s  Yes  No
sarcoma)?
67.1.1 If yes, what and when? ..................................................................
67.1.2 What treatment did you receive? …………………………………………………..
CAN/CSA-Z900.2.3-12; Section 13.1.2
68. 68.1 Have you ever been diagnosed with West Nile Virus (WNV) or suspected of
having WNV?
68.1.1 If yes, where and when? …………………………………
 Yes  No
CAN/CSA –Z900.2.3-12 Section 12.2.2.3 (d)
69. Has a doctor or health care professional:
69.1 Diagnosed you with H1N1 Influenza A
69.2 Tested you for H1N1 Influenza A
69.3 If yes, to 69.1 or 69.2, explain: ………………………………………..........
………………………………………………………………………………………………....
70. 70.1 In the past 12 months, have you been exposed to known or suspected viral
hepatitis or HIV infected blood through an accidental needle stick or through contact
with an open wound or mucous membrane or via sexual contact?
70.1.1 If yes, where and when? ……………………………………………………………..
 Yes  No
 Yes  No
 Yes  No
CAN/CSA-Z900.1-12; Annex E.1 (e)
71. 71.1 In the past six months have you been bitten by an animal suspected of having
rabies?
71.1.1 If yes, please describe: ……………………………………………………………..
…………………………………………………………………………………………………………….
 Yes  No
CAN/CSA- Z900.1-12; Section 13.1 3 (h)
72. 72.1 In the last 5 years (12 months in some centres), how many sexual partners or
intimate partners have you had? ………….
73. 73.1 Have you ever tested positive or been treated for an STD?
73.1.1 If yes, please describe: …………………………………………………………
…………………………………………………………………………………………………………
73.2 Have you ever tested positive for syphilis?
 Yes  No
 Yes  No
CAN/CSA-Z900.2.3-12; Section 13.1.2
74. 74.1 In the past 6 months have you had sex with someone whose sexual background
you don’t know?
 Yes  No
75. 75.1 At any time in the last 12 months have you or any sexual partner, had sex with
anyone who has AIDS or has known or suspected as being HIV positive or have  Yes  No
hepatitis B or hepatitis C?
75.1.1 If yes, when did this occur? ....................................................
CAN/CSA-Z900.1-12; AnnexE.1 (d)
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76. 76.1 In the past five years, have you or any sexual partner ever used a needle to
inject drugs into your veins, muscle, or under the skin for non-medical use?
 Yes  No
76.2 Have you had sex in the last 5 years with anyone who has ever taken illegal
drugs or illegal steroids with a needle?
 Yes  No
76.2.1 If yes, to either 76.1, 0r 76.2, describe: what, when and for how long?
……………….……………………………….……………...………………………………………………...……..
CAN/CSA-Z900.1-12; Annex E.1 (a)
77. 77.1 Have you ever been tested for HTLV I or II?
77.1.1 If yes, when and what were the results? …………………………………
 Yes  No
CAN/CSA-Z900.2.3-12; Section 13.2.2
78. 78.1 In the past 12 months have you ever been in a correctional facility, prison, or
jail for more than 72 consecutive hours?
 Yes  No
CAN/CSA-Z900.1-12; Annex E.1 (f)
79. 79.1 Have you used any other recreational drugs such as cocaine, heroin, crack, LSD,
Crystal Meth, bennies, uppers, downers, marijuana, hashish, speed, ecstasy or  Yes  No
anabolic steroids?
79.1.1 If yes, what and how long? .....................................................................
…………………………………………………………………………………………………………….…….
80. 80.1 At any time in the past 12 months have you or any partner ever exchanged sex
for money or drugs?
 Yes  No
CAN/CSA-Z900.1-12; Annex E.1 (c)
FOR MALES ONLY
81. 81.1 Have you had sex with a man, even one time in the past 5 years?
 Yes  No
CAN/CSA-Z900.1-12; Annex E.1B
SECTION FOR FEMALES ONLY
82. 82.1 Do you get regular PAP smears?
82.1.1 If yes, date of last PAP? ……………………
82.1.2 What was the result? ………………………………………………
82.2 Have you ever had a mammogram?
82.2.1 If yes, date of last Mammogram? …………………………………………
82.2.2 What was the result? …………………………………………………………….…………
83. 83.1 Are you currently trying to become pregnant?
83.2 Do you have any plans for future pregnancies?
83.3 Do you currently take birth control pills or estrogen/hormone replacement
therapy?
83.4 Have you had a tubal ligation or hysterectomy?
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
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 Yes  No
84. 84.1 Have you ever been pregnant?
84.1.1If Yes, how many pregnancies? …………..
84.1.2 Have you had any miscarriages?
84.1.3 Have you had any abortions?
84.1.4 How many children do you have? List
Gender of children
Age
 Yes  No
 Yes  No
Health
84.2 Were you ever diagnosed with gestational diabetes or pregnancy diabetes?
84.2.1 If yes, describe the treatment you had for the diabetes: ……………….
…………………………………………………………………………………………………………..……..
84.3 Did you have high blood pressure during pregnancy?
84.3.1 If Yes, describe any treatment: (e.g., medication, bed rest)………..
………………………………………………………………………………………………………………….
85. 74.1 In the last 12 months have you had sex with a man who had sex, even one time
in the past 5 years, with another man?
 Yes  No
 Yes  No
 Yes  No
CAN/CSA-Z900.1-12; Annex E.1 (b)
SECTION: OTHER
86. Is there any reason why you think you should not be an organ donor?
(No explanation is necessary )
87. If found to be a suitable donor within what time frame are you hoping to complete
the clinical work-up, and donation surgery? ………………………..
Is there a best time for you to donate? ………………………
If yes; explain ……………………………………………………..
 Yes  No
 Yes  No
OTHER COMMENTS/QUESTIONS:
…………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………
…………
__________________________
Name of Potential Donor
___________________________
Year/Month/Day
___________________________ ___________________
Signature of Potential Donor
Date
___________________________________
CAN/CSA Section 12.2.3 (CAN/CSA-Z900.1-12) (Questionnaire shall be completed by the donor)
Please return completed form to:
For Office use only:
Followup:________________________________________________________________
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________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Questionnaire reviewed by: ___________________________Date: ____________________
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