UMMC Transplant Living Kidney Donor Questionnaire and Referral Form

UMMC Transplant Living Kidney Donor Questionnaire and Referral Form

Kidney Donor Information

First Name and Last Name*

Maiden Name*

Date of Birth*

Email*

Phone*

Phone

Age*

Gender*

Select or enter value

If Other

Height*

Weight*

Race*

Blood Type if known*

Select or enter value

Demographics

Address*

City*

State*

Zip Code*

Country*

Select or enter value

If not in USA, Where?

Medical Information

Past Medical History*

Past Surgical History*

Family history*

Medications*

Social Information

Martial Status*

Employment Status*

Employer*

Insurance Carrier*

Living Accommodation*

Reason for Donation*

Any Additional Comments

Risk Evaluation Questions

Unexpected transmission of Human Immune Deficiency (HIV), Hepatitis C (HCV), and Hepatitis B Virus (HBV) through organ transmission is a patient safety and public health issue. It is for this reason that, per federal regulations, all potential donors much completed the screening questions below. The results of this evaluation will be kept in the strictest confidence.

In the last 30 days, have you:

Had sexual intercourse (vaginal, anal, or oral) with a person known or suspected to have HIV, HCV, HBV?

Had sexual intercourse (vaginal, anal, or oral) in exchange for money or drugs?

Injected drugs by intravenous, intramuscular, or subcutaneous route for non-medical reasons?

Been in lockup, jail, or prison for more than 72 consecutive hours?

Had sexual intercourse (vaginal, anal, or oral) with a person who injected drugs by intravenous, intramuscular, or subcutaneous route for non-medical reasons?

Had sexual intercourse (vaginal, anal, or oral) with a person who had sex in exchange for money or drugs?

I ___ participated in the activites listed above.

Select or enter value

For men only:

In the last 30 days have you had sexual intercourse (anal or oral) with a man?

I_____ .

Select or enter value

Intended Recipient's Information

Do you have someone you would like to donate to?

Select or enter value

Intended Recipient's First Name*

Intended Recipient's Last Name*

Intended Recipient's Date of Birth*

Relationship to Intended Recipient

Consent for Evaluation

By clicking yes in the box below you are given the team consent to review your medical records and evaluate you for donation eligibility.

Yes, I give consent for a donor evaluation.*

Send me a copy of my responses

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