Tell us more!
ONLY Check the box if your answer to the question is
Q1: Did your Doctor tell you that you need organ transplant?
What kind do you need?
Q2: Do you have any medical reports?
Q3: Do you have any blood test results?
Q4: Do you have any X-rays?
Q5: Do you have a list of medications or drugs that you currently take?
Q6: Have you had any surgical operations before?
Q7: Do you have any heart disease?
Q8: Do you have any lung disease?
Q9: Do you smoke?
Q10: Do you drink alcohol?
Q11: Can you walk?
Q12: Do you have diabetes?
Q13: Are you interested in 20 min sessions with the surgeon?
Q14: Are you also interested in getting referred to a Transplant Center?
Q15: Do you have any allergies?
Add any aditional information and any questions you may have!