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- Date of Birth*
- Biological Sex (sex assigned at birth)*
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- Ethnicity/Race (check all that apply)*
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- Which Organ are you considering donating?*
- Do you have a specific recipient you would like to donate to?*
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- Are you currently on any medications?*
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- Have you had any surgeries?*
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- Have you ever been diagnosed with kidney disease?*
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- Have you had more than 2 occurrences of Kidney Stones?*
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- Have you had 2 or more UTI’s (urinary tract infection) in the last 6 months or 3 in the last 12 months?*
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- Have you ever had blood in your urine?*
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- Have you ever been diagnosed with HIV?*
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- Have you ever been diagnosed with Cancer?*
- History of which cancers? (mark all that apply)*
- Has cancer been in remission for 5 years or more?*
- Have you ever been diagnosed with Hep C?*
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- Do you have any autoimmune diseases?*
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- Have you ever been diagnosed with liver disease?*
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- Have you ever had a stroke?*
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- Have you ever had Hypertension (high blood pressure)?*
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- Have you ever had a heart attack or coronary stent?*
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- Have you ever been diagnosed with diabetes (high blood glucose)?*
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- Are you willing to accept blood transfusions?*
- Are you pregnant or breastfeeding or gave birth in the last 12 months?*
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- Have you had a miscarriage?*
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- Have you ever been diagnosed with a mental health disorder?*
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- Have you had suicidal thoughts or attempts in the last year?*
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- Do you smoke tobacco?*
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- Are you currently taking prescription medication to manage a substance use disorder? (e.g. suboxone or methadone).*
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- Do you use any recreational drugs, legal or illegal?*
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- Does anyone in your family have the following? (check all that apply)
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- Is your Mother Alive?*
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- Is your Father Alive?*
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- Should be Empty: