Questionnaire for Living Kidney Donor Evaluation

Name
address

Medical History

Check if allergic to:

Habits

Alcoholic Beverages

Marijuana

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.)