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 specify other race

Ethnicity / Nationality

Please specify other ethnicity

Height

Weight

Last grade completed

Are you Employed

YesNo

Employment

Place of employment

Status

Full TimePart Time

Occupation

Do you have insurance?

YesNo

Are you married?

YesNo

Spouse's Name

Is your spouse agreeable with you donating?

YesNo

If No, why not?

Number of children

Ages of each child

Family History

Other family history

Medications

Do you have any allergies?

YesNo

Please enter your medication list (Medicine / Dose / Frequency / Reason)

Donor Questions

If you are not a match (incompatible) with your recipient would you be interested in paired exchange?

YesNo

Would you be interested in being an altruistic donor? (donating to someone you do not know)

YesNo

Contact Information

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	UTI	No Problems

Diabetes	High blood pressure	Heart disease
Kidney / Bladder problem	Cancer	Other