Questionnaire for Kidney Donor Evaluation

Please complete form and click submit button to securely send to UK Transplant staff.


DONOR INFORMATION  (*Required Fields)
  
  
  
  
  
 
  
 
  
  
 
(000-000-0000) 
(000-000-0000) 
(000-000-0000) 
 
/ (mm/dd/yyyy)  
(000-00-0000)  
Sex: *  
  
  
 feet  inch(es)    
 pounds  
 pounds  
U.S. Citizen: *    
 
  
 
  
Have you ever been treated as a patient at University of Kentucky Hospital? *  

FAMILY HISTORY
Please give a current health history for each relative. Include any chronic diseases, such as diabetes,
high blood pressure, etc. If the relative is deceased, please check the box at left and provide their
cause of death and age at death.
  Relative  Age Comments
Do you work outside the home? *  
 
   
Do you receive a disability check? *  
Does the recipient know of your wish to donate? *  
    
  

 MEDICAL HISTORY 
  
Check if allergic to:          
Do you currently have Health Insurance? *  
       
Habits:      
Smoking: *    
Quit Smoking:   / (mm/dd/yyyy)
Smokeless tobacco: * / (mm/dd/yyyy) 
Alcoholic beverages: *      
   Present:  
Past:  
Recreational Drugs: * / (mm/dd/yyyy) 
   
Marijuana: *      
Present:        
Past:       / (mm/dd/yyyy)
Tattoos: *      / (mm/dd/yyyy) 
 
Exposure to infectious disease:
Hepatitis: *  
Tuberculosis: *  
Chicken Pox: *  
HIV: *
     
Illnesses    
Diabetes (high sugar): *  
Cancer: *  
   
 
   Was it treated?
High cholesterol: *  
High blood pressure: *  
Circulation disease: *  
Muscle disease: *  
Excessive bleeding or bruises: *  
 
Heart and Lungs:
Cough that doesn't go away:  *  
Coughing up blood: *  
Shortness of breath: *  
Night sweats: *  
Chest pain or pressure: *  
Rapid heartbeat/fluttering: *  
Asthma/wheezing: *  
Have you ever had an abnormal EKG?: *  
Have you ever had an abnormal chest X-ray? *  
Have you ever had a heart attack? *  
Have you ever had a pacemaker? *  
Have you ever had a cardiac cath? *  
Have you ever had heart valve replacement? *  
Have you ever had heart bypass surgery? *  
Have you ever had a heart murmur? *  
Have you ever had rheumatic fever? *  
Have you ever had heart valve disease? *  
     
Intestinal:    
Vomiting blood: *  
Gall bladder trouble: *  
Blood in stool/black tarry stools: *  
Hemorrhoids: *  
Jaundice: *  
Ulcers: *  
Have you had a colonoscopy? *  
     
Women's Health:      
       
Do you still have periods?          
  / (mm/dd/yyyy)        
       
During pregnancy, did you require treatment of high blood pressure?  
During pregnancy, did you require treatment of elevated blood sugar?  
 / (mm/dd/yyyy) 
 
Neurologic:
Frequent headaches:  *  
Fainting spells: *  
Convulsions (epilepsy, seizures): *  
Dizzy spells: *  
Depression: *  
Nerve pills: *  
     
Urologic:    
Kidney/bladder infections:  *  
Pain on urination: *  
Blood in urine: *  
Problems emptying bladder: *  
Kidney stones: *  
    
   
Blood/Transfusions:  
    
Have you ever had a transfusion?
Are you willing to accept transfusions?
   
  / (mm/dd/yyyy) 
   
Surgery:
*  
Have you been hospitalized or seen a health care provider in
the last 12 months?