Donor Physical Exam

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DONOR PHYSICAL EXAM Physical exam done by: Unique identifier number (in print letters) Date and time of the exam: : YYYY-MM-DD hh:mm If affirmative answer or if verification impossible, ASSESSMENT YES NO please submit necessary explanations 1. Physical evidence of recent tattoo 2. Physical evidence of ear or body piercings 3. Physical evidence of non medical percutaneous drug use such as needle tracks (including an examination of tattoos as they may cover up needle tracks) 4. Lesion, infection or trauma at the eventual organ retrieval site 5. Presence of cutaneous spots (blue, purple, gray or black) consistent with Kaposi’s Sarcoma or other malignancy 6. Unexplained jaundice, hepatomegaly or icterus 7. Unexplained lymphadenopathy or mucocutaneous lesions 8. Masses suspicious of malignangy (abdominal, breast or other location) 9. Pulmonary lesions on x-ray or chest CT-scan compatible with neoplasia 10. Oral thrush 11. Signs of sexually transmitted diseases such as genital ulcerative disease, herpes simplex, syphilis or chancroid (genital lesions) 12. For a male donor: physical evidence of anal intercourse including perianal condyloma 13. Physical evidence of sepsis (such as unexplained generalized rash) 14. Presence of marks consistent with recent smallpox immunization (large scab, eczema vaccinatum, generalized vesicular rash (generalized vaccinia), severely necrotic lesion consistent with vaccinia necrosum, corneal scarring consistent with vaccinial keratitis) 15. Identified ocular abnormality (e.g. jaundice, sore, tumor, corneal infection) Please complete the back of this document and ensure it is signed and dated. Date d’entrée en vigueur : 2020-05-28 RECTO-VERSO EVA-FOR-007.A version 7 Page 1 de 2 DONOR PHYSICAL EXAM Legend: A Abrasion M Mass SR Skin rash 1 B Burn NTR Nothing to report T Tattoo 2 BP Body piercing OFX Open fracture NT Non-medical needle track 3 CE Contusion / Ecchymosis PFX Penetrating fracture VS Venipuncture site 4 FX Fracture PW Profound wound W Wound L Laceration SI Scar / Incision 5 Comments: Exam done by: Title : Signature of physician Hospital : Date : YYYY-MM-DD Please submit this completed form to the coordinator-clinical advisor in charge of the case. Conformité du présent formulaire vérifié par : Signature du coordonnateur-conseiller clinique Date d’entrée en vigueur : 2020-05-28 RECTO-VERSO EVA-FOR-007.A version 7 Page 2 de 2 .

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Poxviruses: Smallpox Vaccine, Its Complications and Chemotherapy
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