Potential Living Donor Questionnaire
Donor For
Relationship:
Your Name
First
Middle
Last
Email address
Address
Street Address
Apartment number
City
State
Zip
Phone numbers
Home Phone
Work / Mobile Phone
Last 4 of SSN
Date of Birth
Age
Race
Please select...
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Other
Please specify other race
Ethnicity / Nationality
Please select...
American Indian or Alaskan Native.
Asian / Pacific Islander.
Black or African American.
Hispanic.
White / Caucasian.
Multiple ethnicity/ Other
Please specify other ethnicity
Height
Weight
Last grade completed
Are you Employed
Yes
No
Employment
Place of employment
Status
Full Time
Part Time
Occupation
Are you married?
Yes
No
Spouse's Name
Is your spouse agreeable with you donating?
Yes
No
If No, why not?
Number of children
Ages of each child
Medical Information
Have you ever been treated for the following problems?
Check all that apply
Anemia
Bladder Infection
Blood Disorder
Cancer
Diabetes
Gout
Heart Disease
Hepatitis
Herpes
High Blood Pressure
Kidney Infection
Kidney Stones
Liver Diease
Lung Disease
Lupus
Pancreatitis
Seizures
Stroke
Tuberculosis
Have you ever vomited blood or seen blood in your stool?
Yes
No
If you answered yes or selected any of the medical history items, please describe your illness and include how many times you were treated and / or how long you were ill.
What is your blood type?
List 3 blood pressure readings taken on three separate occasions
Date 1
Reading 1
Date 2
Reading 2
Date 3
Reading 3
Potential Living Donor History
Drug Use
Yes
No
What kind?
What kind?
Alcohol Consumption
Yes
No
Frequency
Amount
Tobacco Use
Yes
No
Years used
Amount
Have you ever sought psychiatric help?
Yes
No
Have you visited any country outside the United States in the past six months?
Yes
No
Where have you visited?
Please list all surgeries or major hospitalizations
Family History
Please check if any of your family members have had any of the following medical problems:
Diabetes
High blood pressure
Heart disease
Kidney / Bladder problem
Cancer
Other
Other family history
Medications
Do you have any allergies?
Yes
No
Please enter your medication list (Medicine / Dose / Frequency / Reason)
Donor Questions
1
2
3
4
5
6
7
8
9
10
On a scale from 1 to 10, with 10 being very willing and 1 being not willing at all, how would you feel about being a kidney donor?
If you are not a match (incompatible) with your recipient would you be interested in paired exchange?
Yes
No
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Contact Information
