Date: ____________
MUSC Transplant Program
162 Ashley Ave., MSC 586
Charleston, SC 29425
Phone: (843) 792-1594
Fax: (843) 876-2968
Email: LiveDonor@musc.edu
LIVING DONOR PATIENT HEALTH HISTORY FORM
Transplant Office Use Only:
Donor MRN: ________________ Recipient MRN: _____________
Patient Name:____________________________________________ DOB:_______________________
Address:______________________________________________________________________________
City: ______________________________________________ State: __________ Zip: ____________
Email Address: ________________________________________________________________________
Primary Phone: ____________________________ Work Phone:_______________________________
□ Male
□ Female
Height (in): __________ Weight (lbs): ________ BMI: ______________
SS#: _____________________________________ Blood Type: _______________________________
Marital Status:
□ Married
□ Divorced
□ Separated
□ Widowed
□ Single
Highest Level of Education:
□ None
□ Grade School (0-8) □ High School (9-12)
□ Technical School
□ Associate/Bachelor □ Post-Graduate
Are you employed?
Yes
No
If yes, occupation: ____________________________________________________________________
If no, when did you last work? ___________________________________________________________
Citizenship
□ U.S. Citizen
Ethnicity
□ White
□ Asian
□ Resident Alien
□ Black/African American
□ Hawaiian/Pacific Islander
□ Non-Resident Alien
□ American Indian/Alaska Native
□ Other: ___________________
Recipient Relationship
Recipient Name: ______________________________
Year Entered U.S.: ____
□ Hispanic/Latino
Relationship to Recipient: _________________
Family History (please circle)
Alive?
If yes, Age
Mother
Yes
No
_____years
Father
Yes
No
_____years
Siblings
Yes
No
_____years
_____years
_____years
Other:
__________
Yes
No
_____years
If no, Cause of Death
Known Medical History
Heart Condition
High Blood Pressure
Stroke/Brain Bleed
Heart Condition
High Blood Pressure
Stroke/Brain Bleed
Heart Condition
High Blood Pressure
Stroke/Brain Bleed
Heart Condition
High Blood Pressure
Stroke/Brain Bleed
Diabetes
Blood Clots
Diabetes
Blood Clots
Diabetes
Blood Clots
Diabetes
Blood Clots
Social History (please circle)
Do you currently use?
Have you in the past?
If yes, how much?
If no, date you quit?
Cigarettes
Yes
No
Yes
No
_____ per day
________
Alcohol
Yes
No
Yes
No
_____ drinks per week
________
Recreational Drugs
Yes
No
Yes
No
_____ per week
________
Medical History
List of medications you are taking: ________________________________________________________
Allergies: _____________________________________________________________________________
For women: Number of Children: ____ Ages of Children: __________________________________
□ Gestational Diabetes
□ Pregnancy-induced High Blood Pressure
Do You Have, or Have You Had Any of these Conditions?
□ Anemia
□ Heart murmur
□ Arthritis
□ Heart problems
□ Asthma
□ Heartburn
□ Blood clot
□ Hepatitis
□ Blood disorder
□ High blood pressure
□ Blood transfusion
□ HIV
□ Cancer
□ Jaundice
□ Chest pain
□ Kidney stones
□ Colon problems
□ Liver problems
□ Constipation
□ Mental disorders
□ COPD/Emphysema
□ Migraines
□ Depression
□ Nausea
□ Diabetes
□ Ovary problems
□ Diarrhea
□ Persistent skin rash
□ Gallbladder problems
□ Pneumonia
□ Gout
□ Prostate problems
When was your last procedure?
Month/Year
Colonoscopy
_____/_____
PAP Smear
_____/_____
Mammogram
_____/_____
PSA (Prostate test)
_____/_____
MUSC Living Donor Program, Updated 9/4/14
Not Applicable
N/A
N/A
N/A
N/A
□ Rectal bleeding
□ Seizures
□ Shortness of breath
□ Sickle cell
□ Skin cancer
□ Sores or lumps on skin
□ Stroke
□ Swelling of legs/arms
□ Thyroid disease
□ Tuberculosis
□ Ulcers in stomach
□ Ulcers to feet
□ Urinary tract infection
□ Vision problems
□ Vomiting
□ Other: ___________________
Abnormal?
Yes
No
Yes
No
Yes
No
Yes
No
Location
______________
______________
______________
______________
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Physician Information
Do you currently see any of the following?
Gynecologist
Name: ___________________________________
Primary Care Physician
Name: ___________________________________
Any Other Specialists?
Name: ___________________________________
Specialty: _________________________________
Name: ___________________________________
Specialty: _________________________________
Name: ___________________________________
Specialty: _________________________________
Yes
No
Phone: ___________________________________
Yes
No
Phone: ___________________________________
Phone: ___________________________________
Phone: ___________________________________
Phone: ___________________________________
Signature
I certify that the information provided above is true and accurate.
Patient Signature: _____________________________________________
Date: _________________
Transplant Office Use Only
Recipient ABO: _______ Recipient PRA: _______ Recipient Age: _______ Dx: ________________
Relationship to Recipient: ________________________________________________________________
Recipient Insurance: ____________________________________________________________________
Financial Clearance: ____________________________________________________________________
Recipient Status: ___________________________ Re-Transplant: _____________________________
MUSC Living Donor Program, Updated 9/4/14
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