Living Kidney Donor Questionnaire
Demographic Information
Name
Address
City
State
Country
Zip code
Phone number
Is it okay to leave a message?
Yes
No
Email address
Birthdate
Race
Primary Language
Do you wish to donate a kidney to a specific person?
Yes
No
What is the name of the potential recipient?
What is your relationship with this potential recipient?
Who is your primary care doctor?
Doctor's address (including city, state, country, and zip)
Doctor's phone number
What is your blood type?
Type A
Type B
Type AB
Type O
I'm not sure
Height
Weight
What is your occupation?
Are you currently employed?
Yes, full-time
Yes, part-time
No
Do you currently have health insurance?
Yes
No
Type
Do you live with anyone?
Yes
No
Please specify who
Who would be available to take care of you after surgery?
Medications
Please list your current daily medications
Please list your allergies
Medical History
Have you ever been diagnosed with High Blood Pressure or Gestational Hypertension?
Yes
No
Have you ever had any issues with your lungs or breathing issues?
Yes
No
Have you ever had any problems with your heart?
Yes
No
Have you ever had any problems with your stomach or intestines?
Yes
No
Have you ever been diagnosed with any autoimmune diseases?
Yes
No
Have you ever been diagnosed with any neurologic diseases?
Yes
No
Have you ever had any issues with your nerves or your brain?
Yes
No
Have you ever been diagnosed with blood disorders?
Yes
No
Have you ever been diagnosed with bleeding or clotting disorders?
Yes
No
Have you ever been diagnosed with Cancer?
Yes
No
Have you ever been treated for infections that keep coming back (VRE, MRSA)?
Yes
No
Have you ever been diagnosed with kidney disease?
Yes
No
Have you ever been diagnosed with any problems with your kidneys or bladder?
Yes
No
Have you ever been told you have protein in your urine (Proteinuria)?
Yes
No
Have you ever been told you have blood in your urine (Hematuria)?
Yes
No
Have you ever had an injury to one of your kidneys?
Yes
No
Have you ever taken medications that may have caused an injury to your kidneys?
Yes
No
Have you ever been diagnosed with diabetes, including gestational diabetes?
Yes
No
Have you ever been diagnosed with kidney stones (Nephrolithiasis)?
Yes
No
Have you ever had a urinary tract infection (UTI)?
Yes
No
Do you have any Psychiatric Illnesses?
Yes
No
Do you suffer from Depression?
Yes
No
Have you ever attempted suicide?
Yes
No
Have you ever had a positive test for TB?
Yes
No
Were you treated?
Yes
No
How long did you take medication for treatment?
Have you ever had skin cancer?
Yes
No
Do you have any suspicious skin lesions?
Yes
No
Have you ever been diagnosed with COVID?
Yes
No
When were you diagnosed?
Any other medical history (examples: asthma, epilepsy, heart disease, COPD, etc.)?
Yes
No
Please list
Surgical history - please list all surgeries and years
Cancer Screening
Females
Have you ever had cervical or uterine cancer?
Yes
No
When was your last pap smear test?
Females aged 40 and over
Have you ever had breast cancer?
Yes
No
When was your last mammogram?
Males aged 50 and over
Have you ever had prostate cancer?
Yes
No
When was your last PSA test?
Males and females aged 45 and over
Have you ever had colon cancer?
Yes
No
When/where was your last colonoscopy?
Smokers, past and current
Have you ever had lung cancer?
Yes
No
Family History
Has anyone in your family been diagnosed with:
Coronary artery disease?
Yes
No
Please specify which family member
Cancer?
Yes
No
Please specify which family member
Diabetes?
Yes
No
Please specify which family member
Kidney Disease?
Yes
No
Please specify which family member
Hypertension?
Yes
No
Please specify which family member
Kidney Cancer?
Yes
No
Please specify which family member
Genetic diseases of the kidneys?
Yes
No
Please specify which family member
Social History
Do you currently smoke?
Yes
No
What year did you start smoking?
How many cigarettes or packs do you smoke in a day?
Do you drink alcohol, wine, or beer?
Yes
No
How many drinks do you have per day?
Do you currently or have you ever used any street drugs?
Yes
No
Please explain
Marital status?
Married
Single
Divorced
Separated
Do you have children?
Yes
No
Please specify ages
COVID Vaccine and Boosters
Have you received the COVID-19 vaccine?
Yes, I have received both doses (1 and 2)
Yes, I have received only the first dose
No, I have not received the COVID-19 vaccine
Prefer not to answer
#1 Date
#1 Type
#2 Date
#2 Type
#3 Date
#3 Type
#4 Date
#4 Type
#5 Date
#5 Type
#6 Date
#6 Type
Any additional vaccines and/or boosters, please provide date and type
Is there any other information you would like to provide?
Contact Information
