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A PROJECT OF
ROOMI FOUNDATION
A PROJECT OF
ROOMI FOUNDATION
A PROJECT OF
ROOMI FOUNDATION
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Liver Recipient
Don’t take your organ to heaven
Heaven knows we need them her
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Liver Recipient
Recipient Personal Details
First Name
Last Name
Father/Husband Name
Address
Country
Select Country
Pakistan
Overseas
Province
Select Province
District
Select District
Gender
Select Gender
Male
Female
Transgender
CNIC No.
Date of Birth
Age
Email
Mobile No.
Landline No.
Occupation
Height (cm)
Body Weight (kg)
Next of Kin Details
Name
CNIC No.
Relationship with Recipient
Select Relationship
Father
Mother
Son
Daughter
Brother
Sister
Husband
Wife
Address
Country
Select Country
Pakistan
Overseas
Province
Select Province
District
Select District
Mobile No.
Landline No.
Email
History of Medical illness of Recipient
High Blood Pressure / On Treatment for Hypertension
Select Option
Yes
No
Diabetes / On Treatment for Diabetes
Select Option
Yes
No
Active Hepatitis B (PCR +ve)
Select Option
Yes
No
Active Hepatitis C (PCR +ve)
Select Option
Yes
No
HIV
Select Option
Yes
No
History of Drug Abuse (in last ten years)
Select Option
Yes
No
History of Cancer
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Yes
No
History of Regular Alcohol Intake
Select Option
Yes
No
Any Other Disease
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Rheumatiod Arthritis
SLE
Chronic UTI / Kidney Disease
STDs (Sexually Transmitted Disesases)
CMV infection
Select Option
Yes
No
Sphilis
Select Option
Yes
No
For Liver Recipient
Blood Type
Select Option
A
B
AB
O
Complete Blood Count (CBC)
Hemoglobin (Hb)
Hematocrit (Hct)
White Blood Cells (WBC's)
Platelets
Mean Corpuscular Volume (MCV)
Red Blood Cell Count (RBC)
Electrolytes
Sodium (Na⁺)
Potassium (K⁺)
Chloride (Cl⁻)
Bicarbonate (HCO₃⁻)
IGRA TEST
Select Option
Yes
No
Liver Enzyme
Total Bilirubin
Alanine Aminotransferase (ALT)
Aspartate Aminotransferase (AST)
Coagulation Profile
Prothrombin Time (PT)
International Normalized Ratio (INR)
Endiocardiography Upload File (PDF, PNG, JPG, JPEG):
LIVER Recipient
Albumin Levels
Ammonia Levels
Abdominal Ultrasound
Select Option
Normal
Shrink
Fatty
Upload Reports
Liver Biopsy Report Upload (PDF, PNG, JPG, JPEG):
Echocardiography Report Upload(PDF, PNG, JPG, JPEG):
CT Scan Abdomen
CT Scan Abdomen Report Upload (PDF, PNG, JPG, JPEG):
CT Scan Abdomen Remarks
Submit Details
