Questionnaire for Living Kidney Donor Evaluation

Thank you for taking the first step to be evaluated as a potential living kidney donor. Please complete the following questionnaire. All fields in this form are required to be asked. If a question does not apply to you, simply enter N/A in that field.

Date

Are you seeking evaluation as a potential donor for a specific recipient?

Yes

Recipient First Name

Recipient Middle Name

Recipient Last Name

Recipient Date of Birth

Recipient Phone Number

Recipient Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Your relationship to the recipient

Does the recipient know of your wish to donate?

Please complete the remainder of this questionnaire, answering the questions as they pertain to you.

First

Middle

Last

Address

City/Town

State/Province

ZIP/Postal Code

Phone

Date of Birth

Gender

Marital Status

Race

Height

Weight

Weight One Year Ago

U.S. Citizen

If no, explain:

Where were you born?

Have you lived/traveled to Southeast Asia (Vietnam, Cambodia, Laos), Africa, Central or South America?

Mother's Maiden Name

Name of Spouse / Significant Other

Spouse / Significant Other Phone

Do you work outside the home?

Describe your occupation.

Name of Employer

How long have you been at this occupation?

Will being off work put your job in jeopardy/cause unmanageable financial problems?

Do you receive a disability check?

If yes, what is your disability?

Have you ever been treated as a patient at the University of Kentucky?

Medical History

List all current medications and the reason you are taking them. Include any pain medicines, “nerve” pills, over-the-counter, and herbal supplements.

Do you frequently use ibuprofen, naproxen, etc?

Check if allergic to:

Eggs

Soybeans

Shellfish

PABA (sunscreen)

Latex

None of the above

Allergies: (to medications and other allergies, explain the reaction)

Do you currently have Health Insurance?

Habits

Do you smoke cigarettes?

How many packs per day?

How many years have you smoked?

How many years did you smoke?

When did you quit smoking?

Do you use smokeless tobacco?

Do you currently drink alcoholic beverages?

How often do you currently have a drink containing alcohol?

How many drinks containing alcohol do you have on a typical day when you are drinking?

Did you drink alcoholic beverages in the past?

In the past, how often did you drink alcohol?

In the past, how many drinks containing alcohol did you have on a typical day when you were drinking?

Do you use recreational drugs?

What type(s)?

Did you use marijuana in the past?

Do you currently use marijuana?

Do you have tattoos?

Date of most recent tattoo:

Illnesses/Exposure to Infectious Disease

Have you been diagnosed with hepatitis?

What type?

When were you diagnosed with hepatitis? (If you do not remember the exact date, guess as closely as possible.)

Have you been diagnosed with diabetes?

When were you diagnosed with diabetes? (If you do not remember the exact date, guess as closely as possible.)

Are you undergoing treatment for diabetes?

What kind of treatment?

How long have you been treated for diabetes?

Have you been diagnosed with cancer?

What type?

How long ago were you diagnosed with cancer?

Did you undergo cancer treatment?

Have you ever screened for skin cancer?

When and where did your most recent screening take place?

Have you had tuberculosis?

Have you had chicken pox?

Have you had HIV?

Have you had high cholesterol?

Have you had high blood pressure?

Have you had circulation disease?

Have you had muscle disease?

Have you had excessive bleeding or bruises?

Do you have a clotting disorder?

Heart and Lungs

Do you have a cough that doesn’t go away?

Are you coughing up blood?

Do you have shortness of breath?

Do you have night sweats?

Do you have chest pain or pressure?

Do you have a rapid heartbeat or fluttering?

Do you have asthma or wheezing?

Have you ever had an abnormal EKG?

Have you ever had an abnormal chest x-ray?

Have you ever had a heart attack?

Do you have a pacemaker?

Have you had a cardiac cath procedure?

Do you have heart valve disease?

Have you had a heart valve replacement?

Have you had heart bypass surgery?

Do you have a heart murmur?

Have you had rheumatic fever?

Intestinal

Do you have a history or vomiting blood or have you ever vomited blood?

Have you had blood in your stool or black tarry stool?

Do you have jaundice?

Have you had a colonoscopy?

When and where did your most recent colonoscopy take place?

Women's Health

Have you had a Pap smear?

When was your last Pap smear?

Where did you have your last Pap smear? (Please include doctor and center name.)

Have you been pregnant?

How many pregnancies have you had?

During pregnancy, did you require treatment of high blood pressure?

During pregnancy, did you require treatment of elevated blood sugar?

Have you had a mammogram?

When was your last mammogram?

Where did you have your last mammogram? (Please include doctor and center name.)

Neurologic

Have you ever had a stroke?

Have you ever had seizures?

Have you ever had depression?

Have you ever had anxiety?

Urologic

Have you ever had a kidney and/or bladder infection (also called a urinary tract infection or UTI)?

When was your last UTI?

How many UTIs have you had in the past 5 years?

How many UTIs have you had in your lifetime?

Have you required treatment for UTIs?

What kind of treatment have you undergone for UTIs?

Do you have painful urination?

Have you had blood in your urine?

When is the last time you noticed blood in your urine?

Have you been evaluated or treated for blood in your urine?

Where were you treated?

Do you have problems emptying your bladder?

Have you had kidney stones?

How many?

Describe other known information about your kidney stones. Did you have them in your left kidney, right kidney, or both? What kind of treatment did you receive? When and where?

Blood Transfusions

What is your blood type? (If known)

Have you ever had a transfusion?

Are you willing to accept transfusions?

Surgery

List any operations, dates, and reason for surgery

With previous anesthesia, did you have any unexplained fever, or any other problem?

Have you been hospitalized or seen by a health care provider in the last 12 months?

Please give dates & reason(s):

Have you had lab work done in the last 6 months?

Where?

Family History

Please give current health history of each relative. Include any Chronic Diseases such as Diabetes, High Blood Pressure, Kidney Disease, etc. (If deceased, please list cause of death and age at death.)

Father

Mother

Do you have any brothers or sisters?

Brother/Sister 1

Do you have a second brother or sister?

Brother/Sister 2

Do you have a third brother or sister?

Brother/Sister 3

Do you have a fourth brother or sister?

Brother/Sister 4

Do you have any additional siblings?

Additional Sibling(s)

Do you have any children?

Children

Appointment

Doctor

MyChart