Q1-3:Clinical Status of Recipient Prior to the Preparative Regimen (Conditioning)

*Infusion Without a Preparative Regimen
This section must be answered even if no preparative regimen was given.

Question 1: Does the recipient have a history of smoking or using chewing tobacco?

The intent of this question is to determine the recipient’s history of smoking, including cigars, pipe tobacco, e-cigarettes, and marijuana, and / or use of chewing tobacco. The recipient’s smoking and / or chewing history is usually documented on the transplant admission summary.

Indicate whether the recipient has a history of smoking or chewing tobacco.

Question 2: Specify smoking or chewing use (check all that apply)

Indicate the recipient’s smoking and / or chewing tobacco use from the options listed. Check all that apply. Select Chewing tobacco if the recipient has a history using naswar and / or paan.

Question 3: Has the recipient smoked cigarettes within the past year?

Indicate if the recipient has a history of smoking cigarettes within the year prior to HCT. Do not include chewing tobacco, cigars / pipe, e-cigarettes, or marijuana.

Section Updates:

Question Number	Date of Change	Add/Remove/Modify	Description	Reasoning (If applicable)
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