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Whole-Body Donation
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  - Miami
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Donor Body Registration – Step 5

Other Medical History About the Donor

Has the potential donor had a history of any of these? Please select any that apply.

Arthritis or joint disease

Yes

No

Please explain and include when.

Please explain and include when.

Broken bones, osteoporosis, or carpal tunnel syndrome

Yes

No

Please explain and include when.

Please explain and include when.

High blood pressure, heart disease, chest pain, or a pacemaker

Yes

No

Please explain and include when.

Please explain and include when.

Poor circulation, especially in the legs

Yes

No

Please explain and include when.

Please explain and include when.

Asthma, emphysema, chronic bronchitis, copd, tuberculosis, or any other respiratory disease

Yes

No

Please explain and include when.

Please explain and include when.

Yellow jaundice

Yes

No

Please explain and include when.

Please explain and include when.

Liver disease

Yes

No

Please explain and include when.

Please explain and include when.

Coming into close contact with anyone who was diagnosed with viral hepatitis in the past twelve months

Yes

No

Please explain and include when.

Please explain and include when.

Kidney-related diseases such as kidney stones or infections

Yes

No

Please explain and include when.

Please explain and include when.

Kidney dialysis within the past twelve months

Yes

No

Please explain and include when.

Please explain and include when.

Urinary tract infections, incontinence, or frequent urination

Yes

No

Please explain and include when.

Please explain and include when.

Neurologic or brain diseases such as alzheimer's, parkinson's, creutzfeldt-jakob disease, or seizures?

Yes

No

Please explain and include when.

Please explain and include when.

Encephalitis, meningitis, multiple sclerosis, or muscular dystrophy

Yes

No

Please explain and include when.

Please explain and include when.

Rapid decline in the potential donor's mental abilities, such as confusion, memory loss, loss of motor control, or sudden and severe personality change

Yes

No

Please explain and include when.

Please explain and include when.

Eye infection, glaucoma, cataracts, or retinoblastoma

Yes

No

Please explain and include when.

Please explain and include when.

Eye or laser surgery

Yes

No

Please explain and include when.

Please explain and include when.

Dental disease or wear dentures

Yes

No

Please explain and include when.

Please explain and include when.

Skin disease, including eczema, psoriasis, or cancer

Yes

No

Please explain and include when.

Please explain and include when.

Diabetes

Yes

No

Please explain and include when.

Please explain and include when.

Recently exhibited flu-like symptoms such as cough, shortness of breath, swollen lymph nodes, nausea, vomiting, night sweats, or fever

Yes

No

Please explain and include when.

Please explain and include when.

Sudden weight loss

Yes

No

Please explain and include when.

Please explain and include when.

Does donor have any spinal deformities, scoliosis/kyphosis/lordosis

Yes

No

Please explain and include when.

Please explain and include when.

About Us

Low Cost Cremation
- Arizona
- Florida
- Nevada
Whole-Body Donation
- Arizona
- Florida
- Nevada

Resources

Start a Donation
- Imminent
- Future Pledge
Contact
- Careers

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