HPC Donor Yearly Follow-Up

Donor family name*
Donor first name*
Date of Birth*
1. How are you feeling physically?*
Is it related to the donation?
If 'yes', please provide details
2. Since we last contacted you, have you been unwell or seen a doctor or any other health care practitioner?*
Provide details
3. Since we last contacted you, have you taken any medication?*
Provide details
4. Since we last contacted you, have you had any skin problems?*
Provide details
5. Since we last contacted you, have you had a serious illness, operation or been admitted to hospital?*
Provide details
6. Since we last contacted you, have you been diagnosed with any type of cancer?*
Provide details
Diagnosis
Diagnosis date
7. Since we last contacted you, have you developed an autoimmune disease?*
Provide details
8. Have you developed any of the following diseases since the last follow-up report?
Systemic lupus erythematosus (SLE, lupus)
Provide details
Rheumatoid arthritis (RA)
Provide details
Vasculitis, inflammation or autoimmune disease of blood vessels
Provide details
Thrombosis, including DVT and thrombophlebitis
Provide details
Multiple sclerosis (MS)
Provide details
Immune thrombocytopaenic purpura (ITP), autoimmune disease of platelets
Provide details
Other autoimmune disorder
Provide details
9. Only for first year follow-up - Have you resumed all your normal physical activity/work?
Provide details
10. Only for second year follow-up - It has been two years since your donation and you will now be re-activated and available for searching. Do you wish to remain on the registry?
11. Are your contact details up to date?*
Provide details
Additional comments
Date follow-up completed:
Email address*