BMT Survivor Volunteer Form

Would You Like to Support Someone about to Undergo a Transplant?

If you or a loved one underwent a transplant and you would be willing to talk to a transplant patient, donor or family member and lend them comfort and support, please fill out the form below.

We are currently in the process of developing a new form that will manage multiple transplants. However, until it is available, please complete a separate form for each transplant, if you have had more than one. We realize this requires duplicative effort however, the information will help us provide the best support possible for current patients.

Please provide us with information on how we can contact you:
* Indicates a required entry

Name:

Address:

City:

State/Province:

Zip/Postal Code:

Country:

One of the following phone numbers is required

Evening Phone:

Day Phone

* (Same as above)

Fax:

* (I don't have one)

E-Mail:

* (I don't have one)

I was the:

(other)

If you are not the patient, what is the patient's name?

Patient's age at time of transplant:

Patient's age now:

Your age at time of transplant:

Your age now:

Patient's gender:

Male Female

If the patient was an adult, did he or she have children living at home?

Yes No

How old were they?

5 or younger 6-11 12 or older

Diagnosis: (e.g., leukemia, breast cancer):

Year of transplant:

Name of transplant center:

State of transplant center:

What types of transplant did you have?

autologous
tandem autologous
allogeneic
syngeneic
allogeneic non-myeloablative (mini-transplant)

What was the source of stem cells?

bone marrow
cord blood
peripheral blood stem cells

If you received bone marrow, stem cells or cord blood from a donor, was the donor?

related
identical twin
unrelated

Was the donor's HLA type (marrow or stem cell type)?

perfect match
mismatch

List complications you experienced after transplant (please check all that apply):

acute GVHD	chronic GVHD	dry eyes	dry skin
contractures	cataracts	joint/muscle pain	bone pain/degeneration
CMV infection	aspergillus infections	shingles	other infections
veno-occlusive disease	liver/kidney damage	breathing difficulties	heart problems
hearing loss	memory problems	learning problems	growth problems
dental problems	sexual difficulties	chronic fatigue	depression
other (please describe)

Did the patient relapse after the transplant?

Yes No

If so, did the patient have:

an infusion of donor leukocytes?

Yes No

a second transplant?

Yes No

other treatment?

Yes No (Please describe)

Is the patient currently alive?

Yes No

Is the patient disease-free?

Yes No

What languages other than English do you speak fluently?

Have you ever provided emotional support to a transplant patient, survivor, donor or their family members?

Yes No

If you have please describe.

Please describe the qualities you possess that would make you a good support person for patients and their loved ones.

Best time to call you:

days evenings either

Would you like us to add your name to the Blood & Marrow Transplant Newsletter mailing list?

Yes No

(Our publications are mailed free of charge. We do, however, ask that you make a contribution to help cover the expense of printing and mailing these items, if you are able.)

A volunteer will contact you by phone to explain our procedures for linking patients with survivors, and to answer any questions you may have. Thanks for offering to help!