Questionnaire - English Version
USC Center for Liver Diseases

You have demonstrated an interest in being a liver transplant donor for your family member or friend. This questionnaire is a simple means of screening individuals who are potential candidates as donors and we appreciate your honest answers to the important questions that comprise the evaluation. [You will be provided a brochure with information regarding the process of selection of donor candidates, the details of the surgery and hospitalization, complications and the advantages of this technique and treatment]. To be completed by each donor.

Attach a report copy of your Blood Type_____________

Recipient name____________________

Donor Name: ____________________

Date of birth:____________ Sex_______ Ht________ Wt:_______[BSA______]

Address_________________________________________________________

Telephone number: Day___________________ Night_____________________

List known medical problems:________________________________________

Specifically: [Yes/No]

Diabetes:____ High blood pressure____ Heart disease_________

Lung disease:____ Kidney disease:____ Bleeding problems:_____

Cancer:__________ Psychiatric____________________________

Blood clots in legs______________ Other____________________

List any current symptoms: [Yes/No]

Breathing difficulty______ Chest pain_______ Leg swelling____________

Weight Loss______ Headache______ Dizziness________ Fatigue______

Pain in extremities:_________ Skin rash:________ Joint symptoms_____

List medications prescribed__________________________________________

List over the counter medications taken within the past 3 months_____________ ________________________________________________________________

Have you used intravenous drugs?___ How long?____ When did you stop?____

Snorted cocaine?____________ How long?_______ When did you stop?______

Used other recreational drugs?________________________________________

Do you smoke?_______ How many years?________ How many per day?_____

Have you received blood transfusions in the past?________________________

Do you drink alcohol?_____ How many years have you been drinking?_______

How many drinks per day?________ How many over the weekend?_________

Date of last drink_____ Do you have other family members who drink?_______

List any operations in the past_______________________________________

Abdominal operations______________________________________________

Recipient name:_____________________ Donor name__________________

What is your relationship to the recipient?______________________________

Why do you wish to be a donor?______________________________________ ________________________________________________________________ ________________________________________________________________

Are you under any pressure to donate?_________________________________

Do you work?_____________________________________________________

Do you have family? Wife/husband_____ Children______ Ages_____________

Other dependants__________________________________________________

Do you live with your family?__________ If not, where?____________________

Are you the sole wage earner in your family?_____________________________

Who will care for your dependants if you are disabled?_____________________

Have you discussed your decision to be a donor with your family?____________

Have they agreed with your decision?_________________________________

Are you able to take 4-6 weeks off work without affecting your job?___________

Have you been disabled before?__________________ State condition________

Claimed disability benefits previously?____ Are you on disability now?________

Other information that you think is important_____________________________ ________________________________________________________________


Please call 323-442-5908 if you have questions
USC Liver Transplantation
Attn: Live Donor Liver Transplantation
Suite 430, Healthcare Consultation Center
1510 San Pablo Street,
Los Angeles, CA 90033