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Gender: Female Male

ONLY Check the box if your answer to the question is 'YES':

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!