Kidney Transplant

Main Content

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. 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
This form was completed by*