Questionnaire for Kidney Donor Evaluation

Please complete form and click submit button to securely send to UK Transplant staff.


DONOR INFORMATION  (*Required Fields)
Name of person receiving your donation: *   
Relationship to person receiving the donation: *   
First name: *   
Middle name: *   
Last name: *   
Maiden name:  
Address line 1: *   
Address line 2:  
City: *   
State: *   
Zip code: *  
Primary number: * (000-000-0000) 
Optional number: (000-000-0000) 
Optional number: (000-000-0000) 
Email: *  
Date of birth: * / (mm/dd/yyyy)  
Social Security Number: * (000-00-0000)  
Sex: *  
Marital status: *   
Race: *   
Height: *  feet  inch(es)    
Weight: *  pounds  
Weight 1 year ago: *  pounds  
U.S. Citizen: *    
If no, explain:  
Mother's maiden name: *   
Name of spouse/significant other:  
Name of employer: *   
Have you ever been treated as a patient at University of Kentucky Hospital? *  

FAMILY HISTORY
Please give a current health history for each relative. Include any chronic diseases, such as diabetes,
high blood pressure, etc. If the relative is deceased, please check the box at left and provide their
cause of death and age at death.
  Relative  Age Comments
Father
Mother
Brother/Sister
Brother/Sister
Brother/Sister
Brother/Sister
Child
Child
Child
Child
Do you work outside the home? *  
If yes, describe occupation:
How long have you been at this job?  
Will being off work put your job in jeopardy or cause unmanageable financial problems?    
Do you receive a disability check? *  
If yes, what is your disability?
Does the recipient know of your wish to donate? *  
Why do you want to donate? *     
How long have you known the recipient? *   

 MEDICAL HISTORY 
List all current medication: (include any pain medicines, "nerve" pills, over-the-counter and herbal supplements) *
  
Allergies: (to medications and other allergies, explain the reaction)
Check if allergic to:          
Do you currently have Health Insurance? *  
       
Habits:      
Smoking: *      Packs per day for  Years
Quit Smoking:    Date: / (mm/dd/yyyy)
Smokeless tobacco: *  Start Date: / (mm/dd/yyyy) 
Alcoholic beverages: *      
   Present:  Frequency:  Amount:  
Past:  Frequency:  Amount:  
Recreational Drugs: *  Start Date:  / (mm/dd/yyyy) 
Type:     
Marijuana: *      
Present:        Frequency:   
Past:        Date:  / (mm/dd/yyyy)
Tattoos: *       Date of most recent tattoo:  / (mm/dd/yyyy) 
 
Exposure to infectious disease:
Hepatitis: *  
Tuberculosis: *  
Chicken Pox: *  
HIV: *
     
Illnesses    
Diabetes (high sugar): *  
Cancer: *  
   If yes, what type?
   How long ago?
   Was it treated?
High cholesterol: *  
High blood pressure: *  
Circulation disease: *  
Muscle disease: *  
Excessive bleeding or bruises: *  
 
Heart and Lungs:
Cough that doesn't go away:  *  
Coughing up blood: *  
Shortness of breath: *  
Night sweats: *  
Chest pain or pressure: *  
Rapid heartbeat/fluttering: *  
Asthma/wheezing: *  
Have you ever had an abnormal EKG?: *  
Have you ever had an abnormal chest X-ray? *  
Have you ever had a heart attack? *  
Have you ever had a pacemaker? *  
Have you ever had a cardiac cath? *  
Have you ever had heart valve replacement? *  
Have you ever had heart bypass surgery? *  
Have you ever had a heart murmur? *  
Have you ever had rheumatic fever? *  
Have you ever had heart valve disease? *  
     
Intestinal:    
Vomiting blood: *  
Gall bladder trouble: *  
Blood in stool/black tarry stools: *  
Hemorrhoids: *  
Jaundice: *  
Ulcers: *  
Have you had a colonoscopy? *  
     
Women's Health:      
Age at onset of periods:         
Do you still have periods?          
Date of last pap smear:   / (mm/dd/yyyy)        
How many pregnancies?        
During pregnancy, did you require treatment of high blood pressure?  
During pregnancy, did you require treatment of elevated blood sugar?  
Date of last mammogram:  / (mm/dd/yyyy) 
 
Neurologic:
Frequent headaches:  *  
Fainting spells: *  
Convulsions (epilepsy, seizures): *  
Dizzy spells: *  
Depression: *  
Nerve pills: *  
     
Urologic:    
Kidney/bladder infections:  *  
Pain on urination: *  
Blood in urine: *  
Problems emptying bladder: *  
Kidney stones: *  
If yes, how many?     
Any other known information about the stones?    
Blood/Transfusions:  
What is your blood type? *     
Have you ever had a transfusion?
Are you willing to accept transfusions?
How many pints of blood have you received in your lifetime?    
Approximate date of last transfusion:   / (mm/dd/yyyy) 
   
Surgery:
List any operations, dates, and reason for surgery: *  
If you had previous anesthesia, did you have any
unexplained fever or any other problem?
Have you been hospitalized or seen a health care provider in
the last 12 months?
If yes, please give dates and reason:
   
Any other information you believe important for us to know
about your medical history: