LiveWell -

Living Kidney Donor Questionnaire

Prior to completing the referral form below, please review this document for more information about our Kidney Transplant Program.

* = Required

Please note: This form resets after 5 minutes of no activity. This form will take approximately 20 to 30 minutes to complete.

Donor Information

Donor Legal First Name:

Donor Full Middle Name:

Donor Last Name:

Donor Date of Birth:

Donor Sex Assigned at Birth:

Donor Race:

Donor Ethnicity:

Donor Language:

Are you a US Citizen?

Donor Marital Status:

Donor Contact Information:

Cell Phone:

###-###-####

Home Phone:

###-###-####

Address:

City:

State:

Zip Code:

Emergency Contact Information:

Emergency Contact Name:

Relationship:

Emergency Contact Cell Phone:

###-###-####

Primary Care Doctor:

Name:

City:

State:

Phone:

###-###-####

Do you have health insurance?

Medical History:

Height:

Current Weight:

Are you allergic to any drugs, food, or dye?

If yes, please list allergy and type of reaction:

Have you ever experienced any problems with anesthesia?

Are you willing to accept blood and/or blood products?

Have you ever been diagnosed with any of the following?

Heart problems

If yes, what type:

Diabetes (high blood sugar)

If yes, what medications do you take:

High blood pressure

If yes, what medications do you take:

Hematologic issues: Bleeding or clotting disorders, anemia, or sickle cell:

If yes, what type:

Autoimmune disease (Lupus, Fibromyalgia, Celiac, Crohn's)

If yes, what type:

Stomach, bowel or liver problem

If yes, what type:

Chronic Pain

Kidney stones

If yes, how many:

Date of last kidney stone:

Kidney or bladder infection (UTI)

If yes, how often:

Date of last infection:

Blood or protein in urine?

Have you ever had cancer? (including skin cancer)

If yes, what type and when:

Pregnancy complications: high blood pressure, diabetes, pre-eclampsia?

If yes, what type:

Number of pregnancies:

Have you ever had depression/anxiety or other mental health disorder?

If yes, what type:

Have you ever had an eating disorder, bulimia/anorexia?

Have you had a colonoscopy to look for colon cancer?

If yes, when:

Last PAP Smear:

Last Mammogram:

Social History

Do you or have you ever used tobacco products? (i.e., cigarettes, cigars, vaping, dip)

If yes, how much per day?

How many years?

Date quit:

Do you drink alcohol?

If yes, amount and how often:

History of drug abuse?

Additional Information

Medications: Please list medications (including over the counter) that you take on a regular basis. Please include drug name, dose, and frequency:

Surgical History: Please list all your surgeries and dates they occurred

Family History: Please provide medical history including high blood pressure, diabetes, kidney disease, kidney stones, stroke, or cancer:

Recipient Information

Recipient First Name:

Recipient Last Name:

Recipient Date of Birth:

Relationship to Recipient:

Acknowledgement

I agree

Current National and Program specific transplant recipient outcomes are updated every six months and the data can be found on the Scientific Registry of Transplant Recipient at srtr.org. There currently are no national or center specific outcomes for living donors calculated by the Scientific Registry of Transplant Recipient. If you have questions about this data or how to use the website, you can discuss this with your living donor team member.

I have read and understand the patient educational material presented to me for potential living donors. I have answered these questions to the best of my ability and without coercion. I understand that I can change my mind at any time about being a living donor. I would like to proceed with my evaluation if I am an appropriate candidate.

Aurora St. Luke's Medical Center Living Kidney Donor Questionnaire