American Bone Marrow Registry
Your interest in marrow donation is to be commended.
After reading the enclosed information, if you decide to be HLA typed in order
to be listed in the Registry
complete both sides of this form and send to Headquarters or your regional
donor center.
NOTE: Each HLA typing costs the registry $60.00.
Checks made payable to the American Bone Marrow Donor Registry to help defray
all or part of this cost are
considered tax deductible as allowed under law and are acknowledged. Complete the insurance carrier section
below if you think your carrier
might reimburse this cost. Reimbursement
claims will be filed after payment is received.
Mail the
completed forms to Headquarters or
your
____Yes, I do want to be HLA typed for registration
as a marrow donor. Please make the testing arrangements.
The closest hospital or
laboratory to me is:
____I shall take the test kit to my personal
physician so scheduling arrangements are not necessary.
Enclosed is my check for $ _______ OR
Visa /MC# ____ Exp Date____/____ / .
Name
as it appears on card:
___ I am unable to pay for the test at this time,
but would like to be scheduled for testing when funds are available.
Insurance information for possible reimbursement.
Carrier
ID#__________________ Group________________
Carrier Address
_________________________________________________________________________
Subscriber____________________________________________________ D/O/B _ / _ /_____
Employer
______________________________________________________________________________
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MEDICAL
QUESTIONNAIRE
NAME
The following questions are for your protection and
to safeguard the patient who might receive your marrow donation. If you
Have had any illness not covered in the
questionnaire, please tell the technician. THIS INFORMATION IS CONFIDENTIAL
YES answers to #2, #3, or #4 = Permanent Restriction
1. ___ Yes ___ No a.
Are you between the ages 18 and 60 or between the ages of 15 and 18 with signed
parental permission?
2. ___ Yes ___ No Have
you ever had heart disease, cancer, hepatitis, a positive test for hepatitis or
liver disease, or are you
insulin an dependent
diabetic? [Exception: Hepatitis A
is OK]
3. ___ Yes
___No a. Have you ever
taken non-prescribed self injected drugs - EVEN ONCE?
___ Yes ___ No b. Have you been a sex partner with an
IV drug user since 1977- EVEN ONCE?
4. ___ Yes ___ No Have
you ever received Pituitary Growth Hormone?
____ Human
____Recombinant
5. ___ Yes ___ No Have
you ever had any blood disease or
prolonged bleeding?
6. ___ Yes ___ No Have
you ever been deferred as a blood donor (except for weight)?
YES
answers to #7 or #8 = Temporary deferment
for time noted
7. ___ Yes ___ No Within
the past 12 months have you received a blood transfusion, blood injection,
acupuncture,
or tattoos, ear or skin piercing, or an accidental needle stick?
8. ___ Yes ___ No Are you now or have you been pregnant
within the past 4 months?
YES
answers to #9 through
#16 = Require medical
approval
9. ___ Yes ___ No Within
the past 12 months have you been exposed to anyone with yellow jaundice or hepatitis?
10.___ Yes ___ No Within
the past 12 months have you been hospitalized?
11 ___ Yes ___ No Within
the past 12 months have you been exposed to anyone on a kidney dialysis
machine?
12.___ Yes ___ No Within
the past 12 months have you had malaria or taken anti-malarial drugs?
13.___ Yes ___ No Have
you ever had chest pains or shortness of breath?
14.___ Yes ___ No Have
you ever had convulsions, seizures, fainting spells?
15.___ Yes ___ No Are
you taking prescribed medication for a continuing medical problem? List under
"Comments"
16.___ Yes ___ No Have
you ever had herpes?
YES
answers to #17 ,#18,#19, or #20 Are
acceptable
17.___ Yes ___ No Within
the past 12 months have you had any vaccinations or immunizations? List under
"Comments"
18.___ Yes ___ No Within
the past 6 months have you had hepatitis immune globulin?
19.___ Yes ___ No Please
list below and country/countries you have resided in within the past 3 years.
COMMENTS OR
EXPLANATIONS
OF “YES” ANSWERS (#’s 2 T