Living Donor Intake Form

Our Liver Program

Liver Care, Liver Transplantation, and Liver Living Donation

Thank you for contacting the Liver Care and Transplantation programs at MedStar Georgetown Transplant Institute!

Physician referrals and patients looking for more information about our liver care and transplantation program, please only fill out the required fields marked with red asterisks. If you would prefer to call, please contact us at 202-444-0766.

If you are ready for a liver consultation and would like to expedite the referral process with one of our liver specialists, please complete the entire form or contact us at 202-444-0766.

If you are considering living liver donation, please complete the entire form or contact us at 202-444-1360.

Use the Next button at the bottom of the page to continue. Note that the information cannot be reviewed until you click Submit on the final page. All information disclosed in this questionnaire is confidential. A member of the liver team will contact you soon after you click Submit.

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Donor Information

First Name

Middle Name

Last Name

Date of Birth

Gender

US Citizenship

Race

Employment Status

Education

SSN

Height ft in

Weight

Patient Contact Information

Street Address

City

State

Postal Code

Telephone

Section 1: Your Demographic Information

How did you hear about the MedStar Georgetown Transplant Institute?

Other way (please specify)

Primary Language (if other than English)

Would you like an interpreter?

Present Relationship Status

What is Your Occupation?

Emergency Contact Name

Emergency Contact's Sex

Emergency Contact's Phone Number

Emergency Contact Relationship

My preferred contact route is

Your physician's name

Physician's Office Phone

The MedStar Georgetown Transplant Institute has several clinic locations. Where would you prefer to be seen?

Do you have active health insurance?

What is your highest level of education?

If you are currently employed, will you receive paid leave/income during your time off for the surgery and recovery periods?

Who will care for you at home after surgery?

Section 2: Your Intended Recipient

Do you have an intended recipient?

Recipient First Name

Recipient Middle Name or Initial

Recipient Last Name

Recipients Date of Birth

Recipients Gender

How often do you see or speak to the recipient?

What is your relationship to the recipient?

Please tell us what motivated you to want to be considered as a living donor?

Section 3: Your Medical History

Please tell us if you have had any of the following:

Do you have any history of heart disease, high blood pressure, or chest pain?

Do you take medications for heart or blood pressure problems?

If yes: What medications are you taking?

Have you ever had a blood clot or DVT?

Heart Attack

Diabetes

Do you take oral medication for diabetes?

Do you inject insulin for diabetes?

Addiction

What type of addiction

Do you have any mental health illnesses such as depression, anxiety, or bipolar?

If yes, please specify

Do you have a history of any lung diseases such as asthma, COPD, emphysema, or tuberculosis?

If yes: What Disease?

Have you ever been treated for Tuberculosis?

Cancer, Radiation Therapy, or Taken Cancer Drugs

What type of cancer?

When were you diagnosed?

What was the treatment (type and length of treatment)?

When were you last seen by a cancer doctor?

Where were you seen for treatment?

Have you ever suffered from any type of liver disease?

Fatty Liver Disease?

Jaundice (being yellow)

Hepatitis

Have you ever had a positive test for HIV?

Bleeding or clotting disorders

Blood transfusion

Past organ or tissue transplant (bone, cornea, skin, heart, kidney, dura mater, etc)

Previous liver segment donation

Kidney Disease

Kidney Dialysis

Do you or have you ever smoked cigarettes?

For current smokers: How many packs per day?

For current smokers: How long have you been smoking?

For past smokers: When did you quit?

For past smokers: How many packs per day did you smoke?

Do you or have you ever used other tobacco products?

Do you drink alcohol?

If yes: How much alcohol, what type of alcohol, and how often do you drink?

Do you have any history of digestive or intestinal problems

Have you had contact with anyone diagnosed with hepatitis in the past year?

Have you ever been treated for any sexually transmitted disease such as syphilis, gonorrhea, herpes, chlamydia, trichomonas or venereal warts?

Alzheimer?s, seizures, periods of confusion or recent memory loss, or history of brain tumora

Stroke or TIA

Have you ever had a colonoscopy?

Have you ever been treated for substance abuse?

If yes, when and where?

Have you ever been incarcerated?

Section 4: Other Medical History

Do you have an allergy to shellfish, latex, x-ray, or contrast dye:

Do you have any allergies to food or medications:

If yes, please list allergies:

Have you ever used non-prescribed drugs or other substances (cocaine, marijuana, steroids, inhalants, etc)

If yes: What drugs or substances, and by what route (IV, oral, etc)

Have you been seen by a physician, or been hospitalized, in the past two years?

If yes: By what physician, hospital, psychiatric, or long term care facility?

Have you had any other major illnesses or surgical procedures in the past?

If yes: Please list illnesses/surgical procedures below and when they occurred:

Please list any other medications you are taking now, including prescriptions, over-the-counter, herbs, vitamins, or supplements (Please include name, dose and frequency of medications)

Do you have any other health concerns which may prevent you from donating your liver?

Do you have a history of obesity?

Do you have a history of suicide attempts?

Do you have a history of suicidal thoughts?

Have you ever taken medications because of depression, anxiety, or other mental illness or emotional problems?

If yes, what medications, date you last took them and for what diagnosis?

Have you ever traveled or lived outside the U.S?

If so, where and for how long?

Do you agree to accept blood products if necessary?

Section 5: Women Only

Have you had a PAP smear within the last 3 years?

Have you ever had a mammogram?

Have you ever had an abnormal mammogram result?

If yes, please specify

Have you ever been pregnant?

If yes, when were you last pregnant?

Section 6: Family Medical History

Family history of blood clots?

If yes, please specify how they are related to you

Family history of abnormal bleeding issues/ hemophilia?

If yes, please specify how they are related to you

Family history of cancer?

If yes, please specify how they are related to you

Family history of autoimmune disease?

If yes, please specify how they are related to you