If you are in the process of Pre-planning end of life options, or are imminent with 6 months or less diagnosis, these questions are to help determine if you or the potential donor would be a good candidate for tissue donation. These questions will cover topics such as medical history, past surgeries, past diseases, drug use, and highrisk sexual behavior. Please answer the following questions to the best of your knowledge. Answer the questions with a yes or no. If the answer is yes, please explain your response in the space provided. Please note, we are only accepting in Arizona and Florida at this time.

Question Title

* 1. Status of potential donor

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