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Please read and complete this donor packet as thoroughly as possible. If you need assistance, our staff will help you. If you do not know an answer or need clarification to a question, please leave it blank and we will review it with you. Honesty is very important when completing the forms. You will not be judged on your answers. The packet helps us to learn about you and safely guide you through the donor evaluation process. If you have questions, please contact the Transplant Office at (217) 788-3441.

General

Last Name

First/Middle Name

Donating kidney to

How long have you known potential recipient

Height and Weight

Date of Birth

Age

Relationship to potential recipient

Social Security number

Next (Please click the button only one time.)

Demographic Information

Gender Male
Female

Race White
Black
Native American
Asian
Hispanic

Address

City

State

Zip

Home Phone Number

May we leave a voice message Yes
No

Work Phone Number

May we call you at work? Yes
No

Cell Phone Number

May we leave a voice message? Yes
No

Email Address

May we communicate with you by email? Yes
No

Preferred way to reach you Home
Work
Cell
Email

Emergency Contact #1

Name

Relationship to you

Address

Phone #1

Phone #2

May we discuss your medical care and status at the transplant center with your emergency contact(s) Yes
No

Next (Please click the button only one time.)

Personal Statement

Describe in your own words what your reasons are for wanting to donate a kidney?

Next (Please click the button only one time.)

Blood Pressure

You must obtain 3 blood pressure readings on 3 different days. You can go to your local Walgreens, Wal-Mart, supermarket, pharmacy or physician. Please sit/rest for 5 minutes before checking your blood pressure.

First Reading

Date

Blood Pressure

Second Reading

Date

Blood Pressure

Third Reading

Date

Blood Pressure

Next (Please click the button only one time.)

Allergies

Are you allergic to latex Yes
No

Please list any drug or food allergies

Drug

Reaction

Drug

Reaction

Drug

Reaction

Next (Please click the button only one time.)

Medications

Do you take any prescription medications on a regular basis? Yes
No

Do you take an over the counter medications, vitamins, or herbal medications? Yes
No

If yes, please list medications, vitamins, and/or herbal medications and dosages below.

Next (Please click the button only one time.)

Medical History

Have you ever been diagnosed or treated for the following? Check all that apply. Angina
Congestive heart failure
DVT/PE (blood clot)
Change in weight
HIV/AIDS
Alcohol/drug abuse
Cancer (including skin cancers, melanomas)
Venereal disease
Blurred/double vision
Glaucoma
Stroke
Heart attack/heart disease
Kidney stones
Hypertension
Lower extremity edema (swelling)
Peripheral vascular disease
GERD (heart burn)
Kidney disease
Genetic renal disease
Gastrointestinal disease
Infections
Hematologic disorders
Proteinuria
Kidney injury
Nephroly
Thyroid problems
Organ transplant (kidney, liver, cornea, heart, skin, bone, or lung)
Lupus, rheumatoid arthritis or other connective tissue disorders
Frequent vomiting
Liver disease (hepatitis A,B or C, or jaundice
GOUT/Hyperuricemia
High cholesterol
Fibromyalgia
Musculoskeletal disease
Asthma
Obstructive sleep apnea syndrome
Arthritis or swollen joints
Pulmonary hypertension
Irregular menstrual cycles
Abdominal hernia
Chronic migraine headaches
Stress urinary incontinence
Lump in breast
Colon polyps
Chronic constipation
Lung disease (emphysema or bronchitis)
Autoimmune disease
Nuerologic disease
Genitourinary disease
Bleeding or clotting disorders
Hematuria
Diabetes/gestational diabetes
Recurrent urinary tract infections
Tuberculosis or positive TB skin test

Please include any other chronic medical illnesses

If yes to any condition above, please provide date of diagnosis, treatment given and if currently on any medications

Next (Please click the button only one time.)

Medical History: Women Only

What was the date of your last menstrual period?

Have you ever been pregnant? Yes
No

If yes, how many pregnancies?

Did you have any miscarriages? Yes
No

If yes, how many?

Did you have high blood pressure, swelling of the feet or seizures during pregnancy? Yes
No

Did you have diabetes during pregnancy? Yes
No

Date of last mammogram (if over age 40)

Did mammogram show any abnormalities? Yes
No

If yes, please explain.

Date of last Pap smear

Did Pap smear show any abnormalities? Yes
No

If yes, please explain.

Are you currently using any hormonal contraception? (birth control pills, patch) Yes
No

If yes, please name the medication

If no, what are you using for birth control?

If you have stopped your periods, are you using any hormonal medications (hormone replacement therapy) to prevent hot flashes, weakening of the bones (osteoporosis) etc.? Yes
No

If yes, please name medication

Next (Please click the button only one time.)

Other

Do you currently use any tobacco products? Yes
No

If yes, what type of tobacco

If yes, how often and how long?

Do you ever drink alcoholic beverages Yes
No

If yes, how much at a sitting?

If yes, how often?

Have you ever used illegal drugs or substances? (such as cocaine, marijuana, heroin, LSD, steroids, inhalants or other illegal drugs) Yes
No

Have you ever used intravenous drugs (shots into arms, legs, veins, erc.) Yes
No

Have you ever received a blood transfusion or blood products? Yes
No

If yes, please explain when and why?

Were you ever refused as a blood donor, or told not to donate? Yes
No

If yes, please explain when and why?

In the past 3 years, have you traveled outside the United States (except Canada)? Yes
No

If yes, which countries?

Did you take medications to prevent Malaria? Yes
No

Indicate all that apply

Currently taking anti-malaria drugs? Yes
No

Took anti-malaria drugs in the past Yes
No

If yes, when?

History of malaria? Yes
No

Have you ever had close contact with a person diagnosed with viral Hepatitis in the past 12 months? Yes
No

Within the past 12 months, have you received a tattoo, ear/body piercing or acupuncture? Yes
No

If yes, please specify

Have you been incarcerated in a correctional facility or jail? Yes
No

If yes, please list dates of incarceration.

Next (Please click the button only one time.)

Mental Health History

Confirmed mental health diagnosis (check all that apply) Bipolar Disorder
Anxiety or Panic Disorder
Personality Disorder
Psychosis
Depression
Other

If Other, add diagnosis(s)

Mental health treatment? Yes
No

Diagnosis/Reason

Date(s)

Substance Abuse? Yes
No

Substance Abuse Treatment? Yes
No

Substance

Date(s)

Mental Health Hospitalization? Yes
No

Diagnosis/Reason

Date(s)

Eating Disorder? Yes
No

Eating Disorder Treatment Yes
No

Have you ever thought about or attempted suicide? Yes
No

If yes, describe the stress/what was happening in your life at the time.

Next (Please click the button only one time.)

Social

Birthplace (U.S. or other)

Are you a U.S. citizen? Yes
No

Active military? Yes
No

Marital Status Married
Single
Divorced
Widowed
Partnership

If married, how long?

Are you currently employed? Yes
No

If employed, what is your status?

If other

If yes, how long have you been with your current employer?

What is your occupation?

Who lives at home with you?

Will you have assistance at home from friends, and/or family after your surgery? Yes
No

Next (Please click the button only one time.)

Medical Insurance

Do you have medical insurance? Yes
No

If yes, answer the following

Name of company

Name of insured

member ID

Expiration Date

Next (Please click the button only one time.)

Past Surgical History/Hospitalization(s)

Surgery/Hospitalization #1

Date

Reason

Surgery/Hospitalization #2

Date

Reason

Surgery/Hospitalization #3

Date

Reason

Surgery/Hospitalization #4

Date

Reason

Next (Please click the button only one time.)

Family History (Grandparents, Parents, Siblings)

Do you have a family history of: (check all that apply_ Hypertension (High blood pressure)
CHF (Congestive heart failure)
Diabetes
Kidney Problems/Disease
Heart Disease/Coronary Artery Disease
Cancer
Kidney Cancer
Polycystic Kidney Disease
Kidney Stones
Other

If Other, list additional

If yes to any of these, please explain

Next (Please click the button only one time.)

Cancer Screenings

When was you most recent colonoscopy? (required if 50 or older)

When was your most recent prostate exam? (men only)

When was your most recent pap smear? (women only)

When was your most recent mammogram? (women only; 40+ years or history of breast cancer)

Next (Please click the button only one time.)

Psychosocial: Financial

Please mark the statement that best applies to you I'm not able to make ends meet from one month to the next
I often worry about finances
I do not worry about finances
I have extra money to spend or save at the end of the month
I have concerns about out of pocket eing and/or donating my kidney

Next (Please click the button only one time.)

Transportation

How many miles do you live from a transplant center?

Do you have reliable transportation? Yes
No
Not sure

If yes, what type of transportation?

If no, please explain how you plan on getting to and from appointments both before and after surgery?

Next (Please click the button only one time.)

Support

Who is included in your social support system (i.e. specify people who help to pick you up and make you feel better when having a bad day)?

Is your support system in favor of your decision to donate a kidney? Yes
No
Don't Know

If yes, how specifically are they supportive

If no, are there specific reasons they're not supportive and how will you receive support after surgery?

Next (Please click the button only one time.)

Healthcare Providers

Primary Care

Name

Full Address

Phone/Fax Numbers

Cardiologist

Name

Full Address

Phone/Fax Numbers

Psychologist/Psychiatrist

Name

Full Address

Phone/Fax Number

Gynecologist

Name

Full Address

Phone/Fax Numbers

Other

Name

Full Address

Phone/Fax Number

Please list ALL hospital name(s) where you have been treated

Next (Please click the button only one time.)

Patient Responsibility

***NOTICE OF NO SHOW/CANCELLATION POLICY*** I must give at least 24 hours notice if cancelling an appointment with the transplant team with a reason for cancellation(s).

Appointment/Lab Testing: I understand I am responsible for scheduling and keeping physician/lab appointments involved with donor work up and post-donor follow up. If I cancel an appointment, I will give 24 hours notice. It is also my responsibility to come to the appointments ON TIME.

Pre-operative Evaluation/Donor 101: Beginning the donor program pre-operative evaluation process does not guarantee I will be able to donate a kidney. Not all patients are candidates for living donation.

Health Maintenance: Along with the guidance of the transplant team, I understand it is my responsibility to play an active role in my health and wellness. I will obtain all required testing before and after donation as determined by the transplant team and primary care physician.

Financial: I understand all pre-transplant donor testing is to the responsibility of the transplant center. Memorial Transplant Services ONLY pays for testing and diagnostic services related to the evaluation of your suitability as a living kidney donor. If, during the donor evaluation process, a medical condition is discovered that requires further diagnostic testing or treatment beyond that which is needed to determine your suitability as a donor, expenses for the testing or treatment is the f

Transplant Team: I understand that I am responsible for treating all members of the transplant team with courtesy and respect. Verbal abuse, profanity, arguing, demeaning comments, aggressive behavior or continued harassment of multiple phone calls in a short period of time is inappropriate behavior. Non-compliance to this is grounds for dismissal from the program.

By checking this box, you agree to all the terms stated above.

Next (Please click the button only one time.)

Confidential Donor History Questionnaire

Have you truthfully answered all questions about your medical condition and behavioral risk factors to the best of your knowledge? Yes
No

Do now have any concerns that would make you think that you should not proceed with donor work up or surgery? Yes
No

Would you consider donating a kidney if testing showed you to be a good donor and indicated that it would be safe for you to do so? Yes
No

If yes, please indicate below how strongly you wish to donate a kidney by checking the option that most closely matches your interest? Not interested at all
Curious
Interested
Mildly interested
Very interested
Extremely interested

Would you consider donating your kidney in a kidney paired donation or swap? Yes
No

Additional comments (Please refer to section and questions where applicable)

Please note all of your responses are confidential and none of your relatives, including the patient who needs a kidney, will be told any of the information that you submit. Thank you for your time!

I give consent for Memorial Medical Center Transplant Services to perform initial testing (including lab tests, EKG, chest x-ray) to determine whether I may be a suitable kidney donor. I understand that after completing these tests, I will be required to do further evaluations and testing to be approved as a kidney donor.

Submit (Please click the button only one time.)