St. John Medical Center
Please feel free to contact the St. John Transplant Program directly by phone at 918.744.2925 if we can be of further help.
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Donor Information
First Name
Middle Name
Last Name
Date of Birth
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No
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Education
SSN
Height
ft
in
Weight
lbs
kg
Patient Contact Information
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Medical History Referral
Do you have a history of or currently have Diabetes or Blood Sugar Problems?
No
Yes
Do you have a history of or currently have Diabetes or Blood Sugar Problems during pregnancy?
N/A
No
Yes
Are you currently being treated for High Blood Pressure?
No
Yes
Do you take medication for High Blood Pressure?
No
Yes
If you answered "Yes" how many medications are you currently taking?
N/A
1
2
3 or more
Did you have High Blood Pressure or were you treated for High Blood Pressure during your pregnancy?
N/A
No
Yes
Do you have heart problems?
No
Yes
If you answered "Yes" please describe the heart problems:
Do you have a history of kidney stones?
No
Yes
If you answered "Yes" please list the number of episodes:
Do you have a history of urine or kidney infections?
No
Yes
If you answered "Yes" please describe the infections:
Do you have a history of Cancer or ever been treated for cancer?
No
Yes
If you answered "Yes" please describe the cancer further:
Do you have any beliefs that would prohibit you from accepting blood if needed?
No
Yes
Please detail past surgeries:
Please detail current medications:
Who are you interested in donating to?
Recipient First Name
Recipient Last Name
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