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.

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

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

Name
address

 

Medical History

Check if allergic to:

Habits

 

Illnesses/Exposure to Infectious Disease

 

Heart and Lungs

 

Intestinal

 

Women's Health

 

Neurologic

 

Urologic

 

Blood Transfusions

 

Surgery

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.)