Kidney Transplant

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Living Kidney Donor Candidate Screening Form

* - Required Field

Full Name*
Race*
Sex*
Non U.S. resident*
Date of Birth*
Age*
Ethnic Group*
Address*
City, State, Zip*

  -

Best phone number to reach you*
Best time to contact*
Height*
Weight*
Preferred Language:
Email Address:
Secondary Number:
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Phone Number:
Employment Status:
Occupation:
Requires Heavy Lifting:
Has personal or medical leave for donation:
Has Health Insurance:
Blood Type:
Do you have a specific recipient in mind that you want to donate a kidney to?*  

Recipient Information:

Recipient's Name:

Recipient's DOB:

Recipient's Status:

Motivation to Donate:

What is your relationship to your intended recipient?

How did you hear about the person you want to donate to?
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.

 Kidney Disease  


Kidney Damage  


Hematuria  


Proteinuria  


Urinary Tract Infection(s)  

How many episodes:

Last episode:


Kidney Stones  

How many episodes:

Last episode:

Required medical intervention?


Cancer  

Type of cancer:

Year of diagnosis:

Treatment Received:


Blood Clots  


High Cholesterol or Triglycerides  


Heart Attack/Heart Disease/CAD  


Heart Surgery/CABG/Stents  


High Blood Pressure  

Are you currently taking blood pressure medication?

Number of blood pressure medications:


High Blood Pressure During Pregnancy  


Chest Pain  


Shortness of Breath  


Diabetes or High Blood Sugar (incl. Gestational Diabetes)  

Are you currently taking medication to treat diabetes?


HIV  


Stroke  


Lung Disease  

Please specify:


COPD  


Sarcoidosis  


TB  


Asthma  


Respiratory Issues  

Please specify:


Gastrointestinal Issues  

Please specify:


Reflux/GERD  


Gallstones  


Pancreatitis  


Liver Disease  

Please specify:


Hepatitis B  


Hepatitis C  


Bleeding Problems  

Please specify:


Neurological Issues  

Please specify:


Seizures  


Lupus  


Paralysis  


Arthritis  


Rheumatoid Arthritis  


Neuropathy  


Depression  


Anxiety  


Psychiatric Illness  

Please specify:


Thoughts of Suicide  

Please specify:


Suicide Attempts  

Please specify:


Transfusion of Blood or Blood Products  


Obesity  


Fabry's Disease  


Sickle Cell Disease  


Sickle Cell Trait  


Auto-immune Disease  

Please specify:


Are you willing to accept blood transfusions?
Does anyone in your family have the following: Kidney Disease  

Please specify:


Heart Disease  

Please specify:


High Blood Pressure/Hypertension  

Please specify:


Diabetes/High Blood Sugar  

Please specify:


Social History: Has used tobacco:  

Currently uses tobacco:  

Willing to stop for surgery?
Used for how many years?
Tobacco use (packs/cans) per week:
Used for how many years?
Last used:

Has used alcohol  


Currently uses alcohol  

How often?


History of alcohol abuse?


When?


Has used drugs  

Currently using drugs?  

Names and frequency:


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  


Are there any chronic medical conditions, medical or otherwise, that we should be aware of that were not covered?

If yes, list
List any previous surgeries and date of surgery:
List any medication you are taking:
List any allergies
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