Living Donor Screening Tool

  

Personal Information

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First Name (Legal name):
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Middle Initial:
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Last Name:
*
Sex

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SSN
*
Address 1:
Address 2:
*
City:
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State:
*
ZIP:
*
E-mail Address:
*
Phone Number:
*
Best time to contact:

*
Race:
*
Ethnicity:
*
Intended Recipient:
*
Relationship to Recipient:








Relationship to Recipient (If Other):
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How did you hear that this person needed a kidney?








Other Social Media:
*
Select how you would want to receive the living donor packet information.
If you would like to receive the living donor packet information via fax, please provide the number.

Height

*
Feet
*
Inches

Weight

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Pounds
*

Calculate your BMI.

Clicking the link below will open a new page. Use the calculator on that page to determine your BMI, then return to this page and enter that number in the field below.

BMI Calculator


Enter your BMI in the field below.

List any medications you are taking:
*
Blood sugar problems/diabetes?
If you answered yes, you experienced Blood sugar problems/diabetes, please explain further.
*
Blood sugar problems/diabetes during pregnancy?
If you answered yes, you experienced blood sugar problems/diabetes during pregnancy, please explain further:
*
Are you currently being treated for high blood pressure?
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Do you take blood pressure medication?
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Were you treated for high blood pressure during pregnancy?
*
Do you have heart problems?
If yes, you have heart problems, please explain further:
*
Do you have a history of kidney stones/problems?
If yes, you have a history of kidney stones/problems, please explain further:
*
Do you have a history of urine/kidney infections?
If yes, you have a history of urine/kidney infections, please explain further:
*
Have you ever had cancer?
If yes, you have had cancer, please explain further:
*
Do you have a history of mental health disorders?
If yes, you have a history of mental disorders, please explain further:
*
Have you been diagnosed with infectious diseases such as HIV, AIDS, or Hepatitis?
If yes, you been diagnosed with infectious diseases such as HIV, AIDS, or Hepatitis, please explain further:
Any other health issues we should be know about.


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