Please read and complete this donor packet as thoroughly as possible. If you need assistance, our staff will help you. If you do not know an answer or need clarification to a question, please leave it blank and we will review it with you. Honesty is very important when completing the forms. You will not be judged on your answers. The packet helps us to learn about you and safely guide you through the donor evaluation process. If you have questions, please contact the Transplant Office at (217) 788-3441.
Other
Do you currently use any tobacco products?
If yes, what type of tobacco
If yes, how often and how long?
Do you ever drink alcoholic beverages
If yes, how much at a sitting?
If yes, how often?
Have you ever used illegal drugs or substances? (such as cocaine, marijuana, heroin, LSD, steroids, inhalants or other illegal drugs)
Have you ever used intravenous drugs (shots into arms, legs, veins, erc.)
Have you ever received a blood transfusion or blood products?
If yes, please explain when and why?
Were you ever refused as a blood donor, or told not to donate?
If yes, please explain when and why?
In the past 3 years, have you traveled outside the United States (except Canada)?
If yes, which countries?
Did you take medications to prevent Malaria?
Indicate all that apply
Currently taking anti-malaria drugs?
Took anti-malaria drugs in the past
If yes, when?
History of malaria?
Have you ever had close contact with a person diagnosed with viral Hepatitis in the past 12 months?
Within the past 12 months, have you received a tattoo, ear/body piercing or acupuncture?
If yes, please specify
Have you been incarcerated in a correctional facility or jail?
If yes, please list dates of incarceration.