UNOS # NA. Person(s) Interviewed (First and last name) Relationship(s) to him/her. Print Name Title Signature

Transcription

1 UNOS # Form Medical History and Behavioral Donor Name (First and last name) Date/Time of Interview Person(s) Interviewed (First and last name) Relationship(s) to him/her Person Conducting Interview Print Name Title Signature Location of Interview Recorded Phone Interview In Person Do you feel you know him/her well enough to answer questions regarding the medical/social history? Yes How long have you known him/her? Did you live with him/her? Yes Height Weight Age Occupation The interviewer must read all questions as they are worded and read all questions completely and in their entirety before recording the interviewee s answer. The interviewee is to be instructed to answer all questions once they have been read to them completely, and to answer yes or no to the best of your knowledge. The interviewer must comment and elaborate on all questions marked Yes. 1. In the past two years, has he/she: a. Been treated by a physician or seen a family physician? If Yes, at what Hospital/Clinic and physicians name and contact information b. Been hospitalized, in a long-term care or psychiatric facility? If Yes, why, when and where? a. Yes 2. Did he/she ever have: a. Any serious illnesses or infections? If Yes, what and when? b. Any surgical procedures? If Yes, what and when? This PDF is a copy of the form in place as of 04/04/2012. Page 1 of 13

2 3. Was he/she physically active such as exercise regularly, take walks, participate in sports, etc.? UNOS # 4. Did he/she take any medications, vitamins or supplements on a regular basis or recently? If Yes, list. a. Was he/she allergic to any medications? If Yes, list. 5. Did he/she ever use tobacco products? If, skip to question 6. a. If Yes, describe type, amount and duration. b. If stopped, when? _ a. Yes, Packs per day for years _ 6. Did he/she drink alcohol? If Yes, what type, how much, how often and for how long? 7. Did he/she ever use non-prescribed drugs or street drugs either by mouth, inhaling, injecting IV, subcutaneously, in the muscle or any other method? Drugs might include cocaine, marijuana, steroids or inhalants. If Yes, what kind, how much, when, how long and method or route? 8. Did he/she ever use prescribed medications not intended for his/her use? If Yes, what kind, how much, when, how long and method or route? Page 2 of 13

3 UNOS # 9. Has he/she ever been exposed to toxic substances such as lead, pesticides, asbestos or other types? If Yes, when? a. Did this result in symptoms or illness? If Yes, describe. 10. Has he/she ever been an inmate of a correctional system, lock-up, prison, jail, juvenile detention center or juvenile correctional facility for more than 72 consecutive hours? If Yes, when, how long and why? _ 11. Was he/she ever permanently deferred as a blood donor? If Yes, why? 12. Has he/she or any of his/her blood relatives had Creutzfeldt-Jakob Disease (CJD) or variant CJD? a. Was he/she ever told they were at risk for CJD or variant CJD? Page 3 of 13

4 UNOS # 13. Was he/she born, lived or traveled outside of the United States for any purpose including military service? If, skip to question 14. If Yes, ask all questions below. a. Europe: Since 1980 did he/she spend 3 or more months cumulatively in Europe? If Yes, where, when, how long, urban/rural? (For reference: United Kingdom (England, Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar and the Falkland Islands); Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, rway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Turkey, Yugoslavia) b. Africa: Did he/she ever travel to or live in Africa? If Yes, where, when, how long, urban/rural? (For reference: Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger or Nigeria) _ c. Elsewhere: Did he/she travel to places other than Europe or Africa? If Yes, where, when, how long, urban/rural? c. Yes d. While out of the United States, did he/she receive any transfusions of blood or blood components between 1980 until the present? If Yes, where, when? d. Yes 14. In the last 3 years, has he/she been diagnosed, treated or taken medication for Malaria or Chagas disease? Page 4 of 13

5 UNOS # 15. Was he/she ever diagnosed with or suspected of having Severe Acute Respiratory Syndrome, also known as SARS or had close contact with anyone known or suspected to have SARS? If Yes, when? If, skip to question 16. a. If Yes, what were his/her symptoms, when did they start and when was treatment stopped? b. If Yes, what were the symptoms of the person in close contact, when did they start and when was treatment stopped? 16. Has he/she received human-derived clotting factor concentrates for hemophilia or related clotting disorders in the past 5 years? a. In the last 12 months, had sexual relations with someone who had received human-derived clotting factor concentrates? 17. Was he/she ever given human pituitary derived growth hormone? If Yes, when, what type, for example human, bovine or synthetic and why? 18. Did he/she ever have an organ, tissue or cellular transplant such as bone, cornea, dura mater, stem cells or Epicel from a human or animal source or have intimate contact with anyone who has received such a transplant? If Yes, transplant type and date. (For reference, Epicel is a cultured epidermal autograft grown from patient s own skin cells and co-cultured with mouse cells. It is a permanent skin replacement product manufactured in the US.) 19. Has he/she ever received blood transfusions or blood products? If Yes, what type, when and where, including the country? Page 5 of 13

6 UNOS # 20. Did he/she have any tattoos, piercings, acupuncture or accidental needle stick? If Yes, where, body site, when, by whom including the facility name, state and country and how many? If, skip to question 21. a. Were shared and/or contaminated needles, ink or instrumentation known to have been used? 21. In the past 12 months did he/she get bitten from or have close contact with an animal suspected of rabies, or a species known to harbor rabies, such as bats, skunks, unvaccinated dogs or cats, raccoons or squirrels? If Yes, describe and include type of treatment. 22. In the past 12 months was he/she vaccinated or immunized for any reason such as influenza, small pox, hepatitis B, tetanus? a. If Yes, when, what type and route? Were there any known complications from the vaccination? (For small pox, has the vaccination site healed, has the scab fallen off or was it manually removed?) b. Did he/she have close physical contact with someone who received the small pox vaccine? If yes, describe any complications that may have resulted. _ 23. Did he/she have: a. Influenza like symptoms, including a temperature of 100 F or greater and a cough and/or a sore throat of unknown origin in the past two weeks? If Yes, what was the date of onset? b. Did he/she have a recent diagnosis of H1N1 or influenza? c. Did he/she have a recent household exposure to an individual with an influenza-like illness? If Yes, what was his/her relationship to the individual he/she was exposed to such as., spouse, sibling, child, or others? What was the duration of exposure? c. Yes Page 6 of 13

7 UNOS # 24. In the last 5 years, has he/she: a. Been sexually active, including oral, anal or vaginal? b. Been sexually assaulted? Briefly describe if assaulted. If to both a. and b., skip to question 25. If Yes, to either a. or b., ask all questions. c. In the last 5 years, engage in sex in exchange for money or drugs or sexually active in the last 12 months with anyone who has? d. In the last 12 months, sexually active with anyone who, in the last 5 years, has injected drugs for nonmedical reasons, including intravenous, intramuscular or subcutaneous injections? e. In the last 12 months, been sexually active with anyone known or suspected to be infected with HIV or viral hepatitis B or C? f. Has he/she had a sexual partner or close contact with anyone who was born or lived in Central Africa since 1977? (For reference: Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger or Nigeria) g. For Male Donors Only: To the best of your knowledge was he sexually active with another male in the last 5 years? h. For Female Donors Only: To the best of your knowledge, in the last 12 months, was she sexually active with a male who has had sex with another male in the last 5 years? a. Yes _ c. Yes d. Yes e. Yes f. Yes g. Yes h. Yes 25. In the past 12 months has he/she been treated for any sexually transmitted disease such as syphilis, gonorrhea, genital herpes or venereal warts? If Yes, describe treatment. 26. Has he/she ever been tested for HIV? If Yes, why, when and result. Page 7 of 13

8 UNOS # 27. Has he/she recently exhibited or experienced: a. Unexplained weakness, fatigue or influenza-like symptoms? (For reference: persistent cough, cold, shortness of breath, swollen lymph nodes for greater than one month, nausea, vomiting or persistent diarrhea?) b. Night sweats or fever > F for greater than 10 days? c. Any unusual blue, purple or white spots on the skin or in the mouth? c. Yes 28. Was he/she exposed to known or suspected hepatitis or HIV-infected blood through accidental needle stick or through contact with an open wound, non-intact skin, or mucous membrane, or lived with such an individual in the past 12 months? 29. In the past 12 months, has he/she lived with any person known or suspected to have viral hepatitis or HIV infection? 30. Did he/she ever have any type of liver disease such as hepatitis, an enlarged liver, cirrhosis, history of jaundice or have a positive test for hepatitis? 31. Did he/she have a history of heart disease, or cardiac infections such as bacterial endocarditis, rheumatic fever, semilunar valvular disease, cardiomyopathy, coronary artery disease, high blood pressure or chest pain? 32. Did he/she have a history of varicose veins, phlebitis, deep vein thrombosis or trauma to his/her legs? 33. Did he/she ever have a history of kidney disease? If Yes, diagnosis, date of diagnosis and treatment. a. If Yes, was dialysis received? List type of dialysis and date of most recent dialysis treatment. Page 8 of 13

9 UNOS # 34. Did he/she have intestinal or digestive problems such as, Crohn s disease, irritable bowel syndrome, bloody stools or intestinal surgery? If Yes, diagnosis, date of diagnosis and treatment. 35. Did he/she have recent weight loss? If yes, how much, when and the Reason. 36. Did he/she have diabetes? If Yes, what type and when was it diagnosed? Did he/she require insulin injections or oral medication? List name of medication and length of treatment. a. Is there a family history of diabetes? Whom? Type and how long? For Female Donors Only: b. History of gestational diabetes? 37. Did he/she have a history of lung disease such as asthma or emphysema? 38. Did he/she ever have tuberculosis (TB) or treatment for TB? a. Did he/she ever have a positive skin test for TB? If Yes, was there follow-up and what type of follow-up? Page 9 of 13

10 UNOS # 39. Has he/she ever had cancer? If Yes, when and what type. If, skip to question 40. a. Ever received radiation therapy, drugs or surgery for cancer? If skin cancer: b. Where was the lesion located on the body? c. When was the lesion removed? d. What were the biopsy results? e. Did it recur? Number of years free of cancer: Date of last cancer checkup: b. c. d. e. Yes 40. Did he/she have a history of an autoimmune or chronic degenerative disease such as systemic lupus erythematosus, polyarteritis nodosa, sarcoidosis, multiple sclerosis, myasthenia gravis or amyotrophic lateral sclerosis also known as Lou Gehrig s disease? 41. Has he/she ever been diagnosed with any of the following neurological or brain diseases: Parkinson s, Alzheimer s, diagnosed dementia, brain tumor, polio, degenerative neurological disease, seizures, encephalitis or other neurological diseases? 42. In the preceding 120 days, was he/she diagnosed for West Nile Virus or suspected to have West Nile Virus? If Yes, describe. a. Did he/she have a fever with a headache in the past week? b. If Yes, were any of the following symptoms also experienced eye pain, body aches, generalized weakness, swollen lymph glands or skin rash? Explain. Page 10 of 13

11 UNOS # 43. Did he/she have any history of arthritis including rheumatoid or osteoarthritis, osteoporosis, or osteomyelitis? a. Has he/she ever had any broken bones? If Yes, what bones and when? 44. Did he/she have a history of skin infections or diseases such as eczema, psoriasis, dermatitis or leprosy? EYE DONORS if not an eye donor 45. Did he/she have a history of glaucoma, cataracts, cornea disease, retinoblastoma or any other diseases, infections or surgeries to the eyes? If Yes, specify. a. Did he/she have an optometrist or ophthalmologist? NO PEDIATRIC DONORS ( 18 months of age or breast fed in last 12 months) if not a pediatric donor 46. Was the child breast-fed within the past 12 months? If Yes, how long? If the child is less than 18 months of age and/or the answer to question 46 is Yes, a separate Medical History and Behavioral and a review of available medical records must be completed for the biological mother. Page 11 of 13

12 UNOS # ALL DONORS 47. Having answered many questions about medical diseases and behavioral risk factors, do you now have any concerns that it might not be safe to proceed with organ or tissue donation? 48. Are there other individuals that may provide additional information regarding any of these questions? If Yes, was additional information obtained and documented? Name Relationship Phone # ADDITIOL COMMENTS: (please refer to question numbers where applicable) Page 12 of 13

13 UNOS # ADDITIOL COMMENTS: (please refer to question numbers where applicable) Page 13 of 13