| Full Name* |
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| Race* |
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| Sex* |
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| Non U.S. resident* |
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| Date of Birth* |
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| Age* |
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| Ethnic Group* |
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| Address* |
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| City, State, Zip* |
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| Best phone number to reach you* |
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| Best time to contact* |
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| Height* |
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| Weight* |
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| Preferred Language: |
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| Email Address: |
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| Secondary Number: |
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| Emergency Contact Name: |
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| Emergency Contact Relationship: |
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| Emergency Contact Phone Number: |
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| Employment Status: |
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| Occupation: |
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| Requires Heavy Lifting: |
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| Has personal or medical leave for donation: |
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| Has Health Insurance: |
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| Blood Type: |
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| Do you have a specific recipient in mind that you want to donate a kidney to?*
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| Please indicate if you have ever been diagnosed or been treated for any of the following conditions.
Please indicate if you have ever been diagnosed or been treated for any of the following conditions.
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Kidney Disease
Kidney Damage
Hematuria
Proteinuria
Urinary Tract Infection(s)
Kidney Stones
Cancer
Blood Clots
High Cholesterol or Triglycerides
Heart Attack/Heart Disease/CAD
Heart Surgery/CABG/Stents
High Blood Pressure
High Blood Pressure During Pregnancy
Chest Pain
Shortness of Breath
Diabetes or High Blood Sugar (incl. Gestational Diabetes)
HIV
Stroke
Lung Disease
COPD
Sarcoidosis
TB
Asthma
Respiratory Issues
Gastrointestinal Issues
Reflux/GERD
Gallstones
Pancreatitis
Liver Disease
Hepatitis B
Hepatitis C
Bleeding Problems
Neurological Issues
Seizures
Lupus
Paralysis
Arthritis
Rheumatoid Arthritis
Neuropathy
Depression
Anxiety
Psychiatric Illness
Thoughts of Suicide
Suicide Attempts
Transfusion of Blood or Blood Products
Obesity
Fabry's Disease
Sickle Cell Disease
Sickle Cell Trait
Auto-immune Disease
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| Are you willing to accept blood transfusions? |
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| Does anyone in your family have the following: |
Kidney Disease
Heart Disease
High Blood Pressure/Hypertension
Diabetes/High Blood Sugar
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| Social History: |
Has used tobacco:
Has used alcohol
Currently uses alcohol
History of alcohol abuse?
Has used drugs
Has had legal issues with law enforcement
Currently incarcerated or serving parole, probation, or house arrest
Has had sex with risk of HIV, Hepatitis B, Hepatitis C
Has had male to male sex
Has has sex with a prostitute
Has had sex in exchange for money, drugs, etc.
Has had sex with someone who uses needles for non-prescription drug use
Has used needles for non-prescription drug use
Has been in jail over 72 hours
Has contracted an STD (sexually transmitted disease)
Has been on dialysis
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| Are there any chronic medical conditions, medical or otherwise, that we should be aware of that
were not covered? |
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| If yes, list |
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| List any previous surgeries and date of surgery: |
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| List any medication you are taking: |
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| List any allergies |
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| This form was completed by* |
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