Specify if the patient has ever had any of the following conditions:
Organ transplant or on organ transplant list? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button 
.
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Liver.
Kidney.
Heart.
Lung.
Pancreas.
Intestine.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Spleen removed? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or enter a description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Optionally, enter up to 60 characters for the description.
Addison’s or Cushing’s disease, chronic steroid use (e.g. prednisone, etc.)? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Addison’s Disease.
Cushing’s Disease.
Chronic Steroid Use: Hydrocortisone.
Chronic Steroid Use: Prednisone.
Chronic Steroid Use: Dexamethasone.
Chronic Steroid Use: Triamcinolone.
Chronic Steroid Use: Celestone.
Chronic Steroid Use: Prelone.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
HIV or AIDS, or do you believe you have been exposed? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
HIV.
AIDS.
Possible Exposure.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Lupus, rheumatoid arthritis, or any autoimmune condition? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Lupus.
Rheumatoid arthritis.
Hashimoto’s Thyroiditis.
Celiac disease.
Graves' disease.
Vitiligo.
Rheumatic fever.
Pernicious anemia.
Immune Thrombocytopenic Purpura (ITP).
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Irritable bowel syndrome, Crohn’s disease, stomach ulcers, or gastric bypass? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Irritable bowel syndrome.
Crohn’s disease.
Stomach ulcers.
Gastric bypass.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Cancer, tumors, chemotherapy, or radiation? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Cancer: Head and Neck.
Cancer: Brain.
Cancer: Breast.
Cancer: Skin.
Cancer: Lung.
Cancer: Prostate.
Cancer: Colorectal.
Cancer: Kidney.
Cancer: Bladder.
Cancer: Non-Hodgkin’s Lymphoma.
Cancer: Thyroid.
Cancer: Endometrial.
Tumors.
Chemotherapy.
Radiation.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Do you take medications that suppress your immune system (e.g. Remicade)? - Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Prednisone.
Tacrolimus.
Cyclosporine.
Mycophenolate.
Imuran.
Rapamune.
Remicade.
Other - With this option selected, an Add description box is available. Optionally, enter up to 60 characters.