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