UNOS #:_______________
CD #:_______________
MEDICAL HISTORY AND BEHAVIORAL RISK ASSESSMENT QUESTIONNAIRE
Person interviewed: _______________________________ Relationship to Patient: ___________________
Person conducting interview: ___________________________ Signature: _________________________
Print
Date and time of interview: ___________/________ Location of interview: ________________________
Yes
No
Do you feel you know the patient well enough to answer questions regarding
medical/behavioral history?
The interviewee should be instructed to answer the following questions "to the best of your knowledge".
The interviewer should comment or elaborate on any questions answered "yes".
GENERAL HEALTH INFORMATION
1. Yes
Has the patient been seen by a physician in the past two years?
No
Physician ______________________________________________________________
Contact Info ____________________________________________________________
Length of time physician has followed pt _____________________________________
Other physician _________________________________________________________
Contact Info ____________________________________________________________
Other physician _________________________________________________________
Contact Info ____________________________________________________________
Yes
No
Has the patient been hospitalized in the past two years?
Hospital/Facility _________________________________________________________
Yes
No
Has the patient been treated in a psychiatric facility in the past two years?
Hospital/Facility _________________________________________________________
2. Yes
Was the patient physically active? (i.e., exercised routinely, took walks, etc.?)
No
Describe exercise _______________________________________________________
________________________________________________________________________
Occupation: _____________________________________________________________
3. Yes
No
Has the patient had sepsis or any other major illnesses or surgical procedures?
List type(s) and date(s) of each:_____________________________________________
________________________________________________________________________
________________________________________________________________________
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UNOS #:_______________
CD #:_______________
4. Yes
Has the patient taken any medications on a regular basis (include over-the-counter, and
herbals)?
Specify medications: ______________________________________________________
No
_____________________________________________________________________
Yes
No
NA
Was the patient compliant with medications?
Yes
No
Was the patient allergic to any medications? _____________________________________
Yes
No
Did the patient have any other allergies (food, latex)? ______________________________
5. Yes
No
Did the patient use tobacco products?
Type of tobacco products: __________________________________________________
Packs per day: __________________________________________________________
For how long: ___________________________________________________________
If the patient stopped using tobacco products, approximate date: ___________________
6. Yes
No
Did the patient drink alcohol?
Type: _________________________________________________________________
Quantity: ______________________________________________________________
How long?_____________________________________________________________
If the patient stopped drinking alcohol, approximate date: ________________________
7. Yes
No
Did the patient ever use non-prescribed drugs or other substances?
(e.g. cocaine, marijuana, methamphetamines, steroids, inhalants)
Type:_______________________________________________________________
How much?__________________________________________________________
How long?___________________________________________________________
Route of administration? ______________________________________
Last time used? ____________________________________________
8. Yes
No
Was the patient ever exposed to toxic substances (e.g. lead, pesticides, or other)?
List substances the patient was exposed to: ___________________________________
If exposed, did this result in symptoms? If yes, explain:___________________________
____________________________________________________________________
Year and duration of exposure: ____________________________________________
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UNOS #:_______________
CD #:_______________
9. Yes
In the past three years, has the patient traveled outside of the United States
(Including Canada)?
Country – Name and Location (City/Region)?________________________________
No
Month and year of stay:_________________ Length of stay:___________________
Purpose of trip: _______________________________________________________
Yes
No
Was the patient born, live in, or stay in any other country (including military bases),
other than United States, for a cumulative period of time greater than 3 months?
Explain:______________________________________________________________
Yes
No
Has the patient ever been diagnosed with Chagas disease?
Explain:______________________________________________________________
Yes
No
Has the patient taken anti-malarial drugs, had malaria, or been in malarial endemic area
within the last year?
Explain: ______________________________________________________________
10. Yes
No
Has the patient ever been diagnosed with, or treated for, West Nile Virus?
Explain:________________________________________________________________
Yes
No
Did the patient have a history of a fever with headache within the last 10 days?
Explain: _______________________________________________________________
11. Yes
No
Has the patient ever received blood transfusions or blood products prior to this admission?
What type, where, and when:______________________________________________
Yes
No
Ever been a blood donor?
Yes
No
Been refused as a blood donor or told not to donate?
Reason:_______________________________________________________________
12. Yes
No
Did the patient ever receive a human or animal organ, tissue, or live cell transplant (i.e.,
bone, cornea, skin, heart, kidney, dura mater, etc.)?
Type of transplant:___________________________________ Date:______________
Hospital/Facility:_______________________________________________________
Yes
No
Did the patient ever have intimate contact * with a person or persons who received an organ
or tissue transplant from a source of animal origin?
Explain: _____________________________________________________________
*Intimate contact defined as sexual partner, shared razors/toothbrush, or laboratory/health care
personnel with repeated mucosal/percutaneous exposure.
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UNOS #:_______________
CD #:_______________
13. Yes
No
In the past 12 months, did the patient have any of the following? tattoos, ear or body
piercing, acupuncture, Botox injections, or accidental needle stick?
Explain: _________________________________________________________________
If yes, answer the following:
Were the instruments used in the procedures listed above shared? ______________
Was it performed professionally? _________________________________________
Explain accidental needle stick injury: _____________________________________
14. Yes
No
In the past 12 months, was the patient bitten by any animal?
Explain (evaluate for suspected rabies): _____________________________________
________________________________________________________________________
15. Yes
No
In the past 12 months, was the patient vaccinated (including flu shots, tetanus) or immunized
for any reason?
Explain: ______________________________________________________________
Date and reason: _______________________________________________________
Yes
No
Was the patient vaccinated for Hepatitis? Reason: _______________________________
16. Yes
No
In the past months, has the patient received the smallpox vaccination, or had close contact
with the vaccination site of anyone else?
Explain: _____________________________________________________________
Yes
No
Did the patient have any illnesses or complications due to the vaccine?
Explain:____________________________________________________________
17. Yes
No
Was the patient ever given human derived pituitary growth hormone?
Explain:_________________________________________________________
Date of treatment:______________________
18. Yes
No
Did the patient have any history of heart disease, chest pain, poor circulation (especially in
the legs), or leg ulcers?
Explain: ______________________________________________________________
Yes
No
High blood pressure?
Duration:__________________________________________________________
Specify medications:__________________________________________________
Yes
No
Yes
NA
No
Was the patient compliant with medications?
Family history of CAD?
Explain: ______________________________________________________________
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UNOS #:_______________
CD #:_______________
19. Yes
No
Did the patient have any type of liver disease? _________________________________
Yes
No
Been told of having any type of hepatitis? Explain: ______________________________
Yes
No
Had a positive test for hepatitis? Explain:______________________________________
Yes
No
Have any history of yellow jaundice? Explain: __________________________________
Yes
No
Did the patient have any close contact with persons diagnosed with viral hepatitis in the
past 12 months?
Explain the nature of the contact (i.e. shared razor, toothbrush, sexual contact) :
_____________________________________________________________________
20. Yes
No
Yes
No
Did the patient have a history of kidney-related diseases, kidney stones, frequent urine
infections, or kidney infections?
Explain: ____________________________________________________________
Ever been treated with kidney dialysis?
Date:____________ Type:___________________ How long?__________________
Hospital/Facility:______________________________________________________
21. Yes
No
Yes
No
Did the patient have a history of digestive or intestinal problems, bloody stools, persistent
diarrhea, intestinal surgery, or intestinal cancer?
Explain: ____________________________________________________________
Recent weight loss?
Explain how much and reason: ________________________________________
Current height:_____________________ Current weight:__________________________
22. Yes
No
Did the patient have a history of diabetes?
If yes, please answer the following:
Age at diagnosis:____________________________________________________
Did the patient require medication? ______________________________________
Specify:__________________________________________________________
Duration of treatment:_______________________________________________
Was the patient compliant with medication? _______________________________
Yes
No
NA
Was the patient diagnosed with gestational diabetes?
Explain: ________________________________________________________
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UNOS #:_______________
CD #:_______________
23. Yes
No
Did the patient have any history of lung disease, asthma, emphysema?
Explain: ________________________________________________________________
Yes
No
Treatment required?
Specify:______________________________________________________________
Yes
No
Yes
No
Did the patient ever receive a TB test?
Was the TB test positive for tuberculosis?
If yes, describe follow-up/treatment:_______________________________________
____________________________________________________________________
24. Yes
No
Has the patient ever had cancer (including lymphoma, leukemia, melanoma, tumor) or
positive biopsies?
Specify medications and other treatments:__________________________________
____________________________________________________________________
If yes, specify number of years cancer-free:_________________________________
25. Yes
No
Does the patient have any history of autoimmune or chronic degenerative disease, such as:
multiple sclerosis, scleroderma, amyotrophic lateral sclerosis (ALS), rheumatoid arthritis,
polyarteritis nodosa, systemic lupus erythematosis, sarcoidosis, or metabolic bone disease?
Approximate onset and treatment of any above disease/diagnosis: ________________
_____________________________________________________________________
26. Yes
No
Did the patient suffer from any type of neurologic or brain disease such as:
Alzheimer's, Parkinson’s, seizures, gait changes, sudden unexplained anxiety or
personality changes, visual changes, hallucinations, periods of confusion or recent
memory loss, dementia, history of brain tumor, polio or degenerative neurological
disease, encephalitis, or meningitis?
Explain: __________________________________________________________
Yes
No
Does the patient or family member have a history of Creutzfeldt-Jakob Disease (CJD) or
a risk of developing CJD?
Explain: ___________________________________________________________
27. Yes
No
Did the patient have any history of:
Bone or joint disease, arthritis, history of broken bones, bone tumor, complaints of stiff or
sore joints?
Explain: ____________________________________________________________
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UNOS #:_______________
CD #:_______________
28. Yes
No
Did the potential donor have a history of skin infections such as leprosy, eczema, dermatitis,
inflammatory skin diseases, or abrasions?
Explain:______________________________________________________________
Yes
No
Does the patient have a current skin problem?
Explain: _____________________________________________________________
HIGH RISK BEHAVIOR QUESTIONS
29. Yes
No
30.
Has the patient received human derived clotting factor concentrates for hemophilia or related
clotting disorders?
Explain: ______________________________________________________________
Has the patient recently exhibited or experienced any:
Yes
No
Unexplained weakness?
Yes
No
Fatigue or flu-like symptoms such as night sweats, persistent cough, shortness of breath,
colds, or swollen lymph nodes for greater than one month?
Yes
No
Nausea, vomiting, persistent diarrhea?
Yes
No
Fever > 100.5 F for greater than 10 days?
Yes
No
White spots in mouth?
Yes
No
Blue or purple spots on the skin or mucus membranes?
Explain: ___________________________________________________________
Yes
No
Has the patient experienced any periods of explained or unexplained weight loss?
Explain: _____________________________________________________________
31. Yes
No
In the past 12 months, has the patient had or been treated for any sexually transmitted
disease (i.e. gonorrhea, syphilis, genital herpes, chlamydia)?
Explain: ______________________________________________________________
Medications: __________________________________________________________
32. Yes
No
Has the patient ever been tested for HIV?
Result and reason for the test: ____________________________________________
33. Yes
No
In the past five years, has the patient used a needle to inject drugs into his/her veins, muscle,
or under his/her skin for non-medical use?
Explain: ________________________________________________________________
34.
Yes
No
NA
Male Donors: Has the patient had sex with another male in the past 5 years?
Yes
No
NA
Female Donors: Has the patient had sex within the last year with a male who has had sex
with another male in the past 5 years?
Explain:________________________________________________________________
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UNOS #:_______________
CD #:_______________
35. Yes
No
Has the patient engaged in sex in exchange for money or drugs in the past 5 years?
Explain:______________________________________________________________
36. Yes
No
Was the patient exposed to known or suspected viral hepatitis or HIV-infected blood through
accidental needle stick or through contact with an open wound, non-intact skin, or mucous
membrane in the past 12 months?
Explain: ______________________________________________________________
37. Yes
No
Was the patient an inmate of a correctional system or jail, or released from a correctional
system or jail, in the past 12 months?
Date:_________________________ Duration:______________________________
Name of facility:_______________________________________________________
Reason for incarceration:________________________________________________
38. Yes
No
Has the patient had sex in the past 12 months with any person known or suspected to have
viral hepatitis or HIV infection?
Explain: _____________________________________________________________
39. Yes
No
Has the patient ever had sex with any person described in the above questions # 29-39 in the
past twelve months?
Explain: _____________________________________________________________
NA
Only complete if patient has a history of Intravenous Drug Use
40.
Frequency of injection of IV drugs?
Explain: ____________________________________________________________
Duration of time that the patient used IV drugs?
Explain: ____________________________________________________________
Last time the patient used IV drugs?
Explain: ____________________________________________________________
Yes
No
Did the patient share needles?
Explain: ____________________________________________________________
Please provide information to verify clean needle use.
Explain: ____________________________________________________________
Yes
No
History of skin abscess, cellulitis, or general sepsis?
Explain: ____________________________________________________________
Yes
No
Did the patient participate in a Methadone or detox program?
When and for how long? ________________________________________________
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UNOS #:_______________
CD #:_______________
PEDIATRIC DONORS
41. Yes
No
Is the child 18 months of age or less?
42.
Yes
No
NA
If under 5 years of age, breast fed within the past 12 months?
If “yes” for question #41 or 42 a Medical History and Behavioral Risk Assessment questionnaire must
be completed by the mother to determine if the child is at risk for transmission of HIV or viral hepatitis
infection.
NA
43. Yes
EYE DONORS
No
Did the patient have a history of any diseases, infections, or surgeries involving the eyes?
Please list: ____________________________________________________________
Yes
No
Did the patient have a history of:
Glaucoma, cataracts, corneal disease, laser surgery, retinoblastoma, lens implant
Explain: _______________________________________________________________
If yes to above, please obtain eye physician name and contact information:
_______________________________________________________________________
44. Yes
No
ALL DONORS
Having answered questions about medical conditions and behavioral risk factors, do
you now have any questions or concerns that would make you think organ or tissue
donation should not proceed?
Please explain your concerns:
_________________________________________________________________________
_____________________________________________________________________
Yes
No
Are there other individuals that may give additional information regarding
medical/behavioral questions?
Name: __________________________________________________________________
Contact Information:
_______________________________________________________________________
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UNOS #:_______________
CD #:_______________
COMMENTS
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