BONE MARROW TRANSPLANT PROGRAM

DONOR ASSESSMENT (to be completed by social worker)

Donor Name:______Age:______Date:______

PERSONAL

Marital Status: Single Committed Relationship Married Separated Divorced Widowed

Length of Marriage/Committed Relationship:______Name of Significant Other:______

Current Member(s) of Household:______

Children:

NAMEAGEM/FCITY/STATE

______

______

______

______

______

Other Family Members:

Parents—

Siblings--

EDUCATION & EMPLOYMENT

Highest level of education:

Less than 12th grade High School/GED Some College College Degree Post Graduate Degree Vocational Training Other

Employment status:

Not Employed Retired Disabled Part-time Full-time Stay at Home Parent Student

Type of work?______

Concerns about leave of absence from work to donate? ______

INSURANCE

Type of Insurance and Prescription Coverage______

DONATION PROCESS

Understanding of diagnosis, transplant, and possible outcomes:

Health concerns related to donating:

Response/Thoughts/Concerns about being the sibling match:

Decision making process in choosing to donate:

DONOR/RECIPIENT RELATIONSHIP AND INVOLVEMENT IN CARE

Quality of the sibling relationship:

Donor’s perception of how sibling recipient feels about donor being a match:

Involvement in care of sibling recipient post transplant:

Feelings about potential positive and negative outcomes from transplant:

COPING

Coping strategies that typically work for donor:

Spirituality as a support:

Donor’s perception of his/her coping:

Donor’s perception of family coping/support:

MENTAL HEALTH

Current treatment for mental health needs? Yes No

If yes, method(s) of treatment:

MedicationIndividual TherapyFamily TherapyCouples TherapyOther______

Past mental health needs? Yes No

If yes, diagnosis and method of treatment?______

Current psychotropic medication:

Medication(s)______Dosage(s)______Prescribing Physician______

Experienced/witnessed any violence or abuse? Yes No ______

HABITS

SubstanceSpecific TypeFrequency of UseAmount used Per day/Per week

Tobacco______

Caffeine______

Alcohol______

MarijuanaN/A______

Other Drugs______

ADVANCE DIRECTIVES

Do you have a living will? Yes No

Do you have a durable power of attorney (health care power of attorney)? Yes No

If you wish, a copy of these documents can be kept on file with the clinic.

CLINICAL ASSESSMENT

To Include Assessment of:

  • Motivation to Donate
  • Level of responsibility felt by donor for sibling recipient outcomes
  • Donor’s overall understanding of process and outcomes
  • Decision making process
  • Quality of relationship with sibling recipient
  • Donor’s ability to cope with poor outcomes
  • Donor support from family
  • Concrete needs of Donor—lodging, financial situation, etc.
  • Donor’s willingness to be followed throughout transplant process