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Living Kidney Donor
Patient Information
First Name
Middle Initial
Last Name
Sex
Male
Female
Social Security Number
Address
City
State
Zip
Email Address
Phone Number
Alternate Phone Number
Is it okay to leave a message on the phone numbers provided?
Yes
No
Best time to contact?
AM
PM
Date of Birth
Age
Race
I am interested in becoming a humanitarian donor
Yes
No
Do you have someone in mind for your donation?
Yes
No
If yes, what is this person's name?
What is your relationship to this person?
Where were you born?
What is your country of citizenship?
Religious Preference
Marital Status
Single
Married
Divorced
Widowed
Life Partner
Do you have an advanced directive?
Yes
No
What is your highest level of education completed?
Are you employed?
Yes
No
If yes:
Full-Time
Part-TIme
What is your occupation?
Emergency Contact
Name
Relationship
Phone Number
Is it okay to talk or leave a message with this contact listed above?
Yes
Name
Relationship
Phone Number
Is it okay to talk or leave a message with this contact listed above?
Yes
Medical History
Height
Weight
Blood type
List any medications you are taking including herbal supplements
Primary Physician's Name
Primary Physician's Phone Number
Date of last visit to your primary physician?
Do you have problems with blood sugar/diabetes?
Yes
No
Did you have blood sugar problems/diabetes during pregnancy?
Yes
No
Are you currently being treated for high blood pressure?
Yes
No
Do you take blood pressure medication?
Yes
No
Were you treated for high blood pressure during pregnancy
Yes
No
Do you have heart problems?
Yes
No
Do you have a history of kidney stones/problems?
Yes
No
Do you have a history of urine/kidney infections?
Yes
No
Have you ever had cancer?
Yes
No
Please list any allergies to medications, foods, environmental.
Date of last colonoscopy?
Date of last mammogram (females)?
Date of last PAP smear/pelvic exam (females)?
Do you have or have you ever been diagnosed with any of the following conditions? Select all that apply.
Bladder Problems
Bleeding Disorder
Cancer
Chick Pox
Chronic Pain
Depression/Anxiety
Diabetes
Gestational Diabetes
Hearing Difficulties
Heart Attack
Heart Disease
High Blood Pressure
High Cholesterol
Kidney or bladder infection
Kidney Stones
Liver Disease
Lung Disease
Peripheral Vascular Disease
Seizures
Sexually Transmitted Disease
Shingles
Sleeping Difficulties
Stroke
Thyroid Disorder
Vision Difficulties
Teeth or Gum Problems
Other Diagnosis
Please list all previous surgeries
Do you use tobacco or have a history of tobacco use?
Yes
No
If yes, how many packs per day?
Do you use recreational drugs?
Yes
No
If yes, please explain.
Do you drink alcohol or have a history of alcohol abuse?
Yes
No
If yes, please explain.
Can you perform daily activities independently?
Yes
No
If no, please explain.
Can you exercise regularly?
Yes
No
Are you willing to accept BLOOD PRODUCTS if needed?
Yes
No
Family History
Please complete this section for immediate family members including adopted relatives.
Father
Age
Alive
Deceased
Cause of death
Sex
Please select...
Female
Male
Is this family member adopted?
Yes
No
Mother
Age
Alive
Deceased
Cause of death
Sex
Please select...
Female
Male
Is this family member adopted?
Yes
No
Add additional siblings by clicking select 'Add another response' in the bottom right corner.
Sibling
Age
Alive
Deceased
Cause of death
Sex
Please select...
Female
Male
Is this family member adopted?
Yes
No
Other
Please share with us why you are interested in becoming a living donor.
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