Please open and read the attachment, "What to Expect as a Kidney Donor." 1 Legal First Name* must provide value
2 Middle Name
3 Last Name* must provide value
Suffix Jr. Sr. II III IV
4 Date of Birth* must provide value
Today M-D-Y 5 Email Address* must provide value
6 Do you live outside the United States?* must provide value
Yes
No
Common Ruleout Factors:
Recipient:"______ , ______ DOB: ______ "
Relationship: "______ "
Donor: "______ , ______ DOB: ______ "
Age: "______ "
Race: "______ " "______ "
BMI: "______ "
HTN: "______ "
Family history of HTN: "______ "
Relationship to Donor: "______ "
DM: "______ "
Family history of DM: "______ "
Relationship to Donor: "______ " Hello, ______ ______ , thank you for beginning the Living Kidney Donor Questionnaire. 1 Today's date* must provide value
Today M-D-Y Today's date (auto)
Now Y-M-D H:M 2 Age View equation
3 Sex* must provide value
Male Female4 Social Security Number
Must be formatted (xxx-xx-xxxx)
Foreign National Number
5 Race* must provide value
Caucasian
African-American
Hispanic
Asian-Pacific
Other
Other Race
6 Mother's Race* must provide value
Caucasian
African-American
Hispanic
Asian-Pacific
Other
Other Race
7 Father's Race* must provide value
Caucasian
African-American
Hispanic
Asian-Pacific
Other
Other Race
8 Primary Language (if other than English)
9 Would you like an interpreter? Yes No10 Citizenship* must provide value
US citizen
Permanent resident / Green card
Other
Citizenship other
11 Present Relationship Status* must provide value
Married
Domestic Partner
Single
Divorced
Widowed
12 Present Employment Status* must provide value
Work full-time
Work part-time
Unemployed
Self-Employed
14 Emergency Contact Name* must provide value
15 Emergency Contact's Sex* must provide value
Male Female16 Emergency Contact's Phone Number* must provide value
17 Emergency Contact Relationship* must provide value
Your Permanent HOME Address (required) 18 Street Line 1
Street Line 2
19 City
20 State/Province
21 Zip Code
22 Country
23 International Home Phone Number
If you do not have a home telephone number, please type your best contact number
24 International Cell Phone Number
25 International Work Phone Number
26 Do you give MGTI your permission to email you your health information? Yes No Preferred Phone Home Cell Work Do you give MGTI your permission to leave your health information in a voicemail to your preferred phone? Yes No Do you have a temporary US address? Yes No18 Street
19 City
20 State Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) District of Columbia (DC) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) .
21 Zip Code
22 Home Phone
If you do not have a home telephone number, please type your best contact number
23 Cell Phone
24 Fax Number
25 My preferred contact route is Home Phone Cell Phone Work Phone .26 I give permission for my personal health information to be shared with me via Home phone via voicemail
Cell phone via voicemail
Email
27 Employer
28 Work Street
29 Work City
30 Work State International address (not USA) Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) District of Columbia (DC) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY)
31 Work Zip Code
32 Work Phone
33 Work Fax
34 Date of last visit
Today M-D-Y 35 Physician's Name
36 Office Street
37 Office City
38 Office State International address (not USA) Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) District of Columbia (DC) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY)
39 Office Zip
40 Office Phone
41 Office Fax Number
1 First Name* must provide value
If you do not have an intended recipient, please type "N/A" into this field
2 Middle Initial
3 Last Name* must provide value
If you do not have an intended recipient, please type "N/A" into this field
Suffix Jr. Sr. II III IV
4 Date of Birth
Today M-D-Y 5 Age View equation
6 Sex Male Female8 I am the Recipient's* must provide value
Sister
Brother
Wife
Husband
Mother
Father
Daughter
Son
Cousin
Aunt
Uncle
Niece
Nephew
Grandparent
Other Relative
Friend
Co-worker
Other non-familial relationship
I do not know the recipient
If you do not have an intended recipient, please select "I do not know the recipient"
Specify Recipient I have never met the recipient
I met the recipient on a website
I do not have an intended recipient
Other
Specify Relationship
Specify Website
1 High Blood Pressure/Hypertension* must provide value
Yes, now Yes, in the past Never2 Heart Attack* must provide value
Yes, now Yes, in the past Never3 Chest Pain with Exercise* must provide value
Yes, now Yes, in the past Never4 Stroke or TIA * must provide value
Yes, now Yes, in the past Never5 If you have had a cardiac stress test in the past, what were the results?* must provide value
Normal
Abnormal
I have never had a cardiac stress test
Don't Know
6 Diabetes* must provide value
Yes, now Yes, in the past Never7 Gestational Diabetes* must provide value
Yes, now Yes, in the past Never How is your Diabetes controlled?
8 Miscarriage* must provide value
Yes, now Yes, in the past Never Please Specify How Many
9 Addiction* must provide value
Yes, now Yes, in the past Never Please Specify Alcohol Drugs Other
If Other, Please Specify
Date of Last Use
10 Cancer* must provide value
Yes, now Yes, in the past Never Specify When
Specify Cancer Type and Location
Specify Cancer Treatment
11 Mental Health Issues* must provide value
Yes, now Yes, in the past Never12 Liver Problems* must provide value
Yes, now Yes, in the past Never13 Hepatitis* must provide value
Yes, now Yes, in the past Never14 HIV* must provide value
Yes, now Yes, in the past Never15 Kidney Disease* must provide value
Yes, now Yes, in the past Never Please Specify Type of Kidney Disease Polycystic Kidney Disease Other Please Provide Disease Details
16 Kidney Stones* must provide value
Yes, now Yes, in the past Never Specify When and How Many
17 Seizures* must provide value
Yes, now Yes, in the past Never18 Suicide Attempts* must provide value
Yes, now Yes, in the past Never Abnormal PAP results* must provide value
Yes No N/A If Yes, Please Specify
Abnormal Mammogram* must provide value
Yes No N/A If Yes, Please Specify
Abnormal PSA* must provide value
Yes No N/A If Yes, Please Specify
Abnormal Colonoscopy* must provide value
Yes No N/A If Yes, Please Specify
20 First Condition
Please leave this field blank if you do not have any other conditions
21 Second Condition
Please leave this field blank if you do not have any other conditions
22 Third Condition
23 Fourth Condition
24 Fifth Condition
Have you ever had surgery in the past?* must provide value
Yes, and I will list them below
No, I have never had surgery
1 First Surgery
Please include the procedure as well the month and year of the operation in the box above
2 Second Surgery
Please include the procedure as well the month and year of the operation in the box above
3 Third Surgery
Please include the procedure as well the month and year of the operation in the box above
4 Fourth Surgery
Please include the procedure as well the month and year of the operation in the box above
5 Fifth Surgery
Please include the procedure as well the month and year of the operation in the box above
If you have had more than 5 surgeries, please list them here
Please include the procedure as well the month and year of the operation in the box above
Do you currently take any prescriptions, over-the-counter drugs, herbs, or supplements?* must provide value
Yes, and I will list them below
No, I do not currently take any prescriptions, over-the-counter drugs, herbs, or supplements
1 First Medication
Please include name, dose, and frequency of the medication in the box above
2 Second Medication
Please include name, dose, and frequency of the medication in the box above
3 Third Medication
Please include name, dose, and frequency of the medication in the box above
4 Fourth Medication
Please include name, dose, and frequency of the medication in the box above
5 Fifth Medication
Please include name, dose, and frequency of the medication in the box above
6 Sixth Medication
Please include name, dose, and frequency of the medication in the box above
7 Seventh Medication
Please include name, dose, and frequency of the medication in the box above
8 Eighth Medication
Please include name, dose, and frequency of the medication in the box above
9 Ninth Medication
Please include name, dose, and frequency of the medication in the box above
10 Tenth Medication
Please include name, dose, and frequency of the medication in the box above
11 Eleventh Medication
Please include name, dose, and frequency of the medication in the box above
12 Twelfth Medication
Please include name, dose, and frequency of the medication in the box above
13 Thirteenth Medication
Please include name, dose, and frequency of the medication in the box above
14 Fourteenth Medication
Please include name, dose, and frequency of the medication in the box above
15 Fifteenth Medication
Please include name, dose, and frequency of the medication in the box above
If you take more than 15 medications, please list them here
Please include name, dose, and frequency of the medication in the box above
Do you have any known allergies to medication or food?* must provide value
Yes, I have alleriges which I will list below
No, I do not have any known allergies
First Allergy
Reaction Rash Itching Difficulty Breathing Other
Please Specify Reaction
Second Allergy
Reaction Rash Itching Difficulty Breathing Other
Please Specify Reaction
Third Allergy
Reaction Rash Itching Difficulty Breathing Other
Please Specify Reaction
Fourth Allergy
Reaction Rash Itching Difficulty Breathing Other
Please Specify Reaction
Fifth Allergy
Reaction Rash Itching Difficulty Breathing Other
Please Specify Reaction
If you have more than 5 allergies, please list them and their reactions here
Are you allergic to Latex? Yes No Please specify your reaction
Are you allergic to Shellfish? Yes No Please specify your reaction
Are you allergic to X-ray or contrast dye? Yes No Please specify your reaction
1 Diabetes* must provide value
Yes No Please specify your relationship with the family member
2 Kidney Disease* must provide value
Yes No Please specify your relationship with the family member
Please Specify Type of Kidney Disease Polycystic Kidney Disease Other Please Provide Kidney Disease Details
3 High Blood Pressure/Hypertension* must provide value
Yes No Please specify your relationship with the family member
4 Cancer* must provide value
Yes No Please specify your relationship with the family member
1 How often do you currently speak with or see the recipient?* must provide value
Every Day
Several times a week
Several times a month
Once a month
Less than once a month
2 Please tell us what motivated you to want to be considered as a living donor* must provide value
3 What personal values led you to register today? * must provide value
4 What is your present (or past) occupation?* must provide value
5 If you are currently employed, will you receive paid leave/ income during your time off for the surgery and recovery periods?* must provide value
Yes No Unknown at this time6 Do you currently have health insurance?* must provide value
Yes No7 Who will take care of you at home after the surgery?* must provide value
8 Have you previously donated blood (if so, how many times?) * must provide value
Never Donated 1-3 Times 4-6 Times 7-9 Times More than 9 Times9 Have you previously donated bone marrow or stem cells? * must provide value
Yes No10 Your highest educational degree* must provide value
Did not graduate grammar school Grammar school diploma High school diploma College graduate Graduate degree
11 Have you ever travelled or lived outside of the US?* must provide value
Yes No12 If so, where and for how long?
13 Do you or have you ever smoked cigarettes?* must provide value
Never
Yes, in the past
Yes, now
How many packs per day and for how long?
How long ago did you quit?
14 Do you or have you ever used other tobacco products?* must provide value
Never
Yes, in the past
Yes, now
What type of tobacco?
How much and how often?
Date of Last Use
Today M-D-Y 15 Do you or have you ever drank alcohol?* must provide value
Never
Drink Socially
Past Social Drinker
Present heavy drinker
Past heavy drinker
How many and how often
Date of last use
Today M-D-Y 16 Do you or have you ever used intravenous drugs?* must provide value
Never
Quit within past year
Quit over a year ago
Still using
Type of Drug
How much and how often
Date of last use
Today M-D-Y 17 Do you or have you ever used any other illegal drugs?* must provide value
Never
Quit within past year
Quit over a year ago
Still using
Type of Drug
How much and how often
Date of last use
Today M-D-Y 18 Have you ever been treated for substance abuse?* must provide value
Yes No When and where were you treated?
19 Have you ever been involved in legal issues involving law enforcement? (including DUI/DWI)* must provide value
Yes No20 Have you ever been incarcerated?* must provide value
I was never in prison or sentenced to be in prison
I was sentenced to be in prison but have not served prison time
I was in prison in the past
When and where?
21 What is your Religion* must provide value
Adventist African Methodist Episcopal Agnostic Amish Anglican Apostolic Assembly of God Atheist Baha'i Baptist Buddhist Catholic Christian Christian Disciple Christian Scientist Church of Brethren Church of God Church of the Nazarene Congregational Disciples of Christ Druid Episcopal Evangelical Friends/ Quaker Greek Orthodox Hindu Holiness Islam Jehovah's Witness Jewish Orthodox Jewish Lutheran Mennonite Mormon Muslim No Religious Preference Non-denominational Pentecostal Polish National Catholic Presbyterian Protestant Reformed Russian Orthodox Seventh Day Adventist Ukrainian Orthodox Unchurch of Christ Unification Church Unitarian Unknown None Other
22 Will you accept blood products?* must provide value
Yes No, I do not accept blood products because of my religious beliefs23 Have you ever taken medications to treat depression, anxiety, or other mental illness or emotional problems?* must provide value
Yes No Please list the name of the medication, date of last use, and diagnosis
24 Have you had a PPD test (Tuberculosis Skin Test) in the last 90 days?* must provide value
Yes No If so, when?
Today M-D-Y 25 How did you hear about the MedStar Georgetown Transplant Insitiute?* must provide value
My Recipient Friend Lecture or Workshop Metro Sign or Bus Wrap Print Ad Physician Radio Social Media Television Web Banner Ad Other
Please specify how you heard
1 Any metal in your body* must provide value
Yes No Specify Where
2 Any piercings* must provide value
Yes No Specify Where
3 Tooth or gum problems* must provide value
Yes No4 Chest pain* must provide value
Yes No5 Fluttering in chest* must provide value
Yes No6 Fainting spells* must provide value
Yes No7 Shortness of breath* must provide value
Yes No8 Wheezing* must provide value
Yes No9 Bloody urine* must provide value
Yes No10 Cloudy urine* must provide value
Yes No11 Sores/ discharge from genitals* must provide value
Yes No12 Abnormal menstrual bleeding* must provide value
Yes No13 Breast tenderness* must provide value
Yes No14 Nipple discharge* must provide value
Yes No15 Anxiety* must provide value
Yes No16 Depression* must provide value
Yes No17 Hallucinations* must provide value
Yes No18 Claustrophobia* must provide value
Yes No19 Low Thyroid* must provide value
Yes No20 What is your weight? (In Pounds)* must provide value
Pounds
21 What is your height? (Feet)* must provide value
Feet
22 What is your height? (Inches)* must provide value
Inches
We need your permission to include you in any type of exchange planning. Please check and sign below if you would consider participating in a paired kidney exchange. We will be happy to answer any questions regarding our exchange program. This is NOT a consent to move forward with surgery. This consent allows us to input your name into our computer system to see if any matches are possible for you or others. If you cannot directly donate to your intended recipient, the only way your recipient can participate in an exchange is with a willing donor. You may not be giving a kidney directly to your recipient, but you are still the sole reason that he/she will be eligible for a living donor! 1 If you were determined not to be a match for your intended recipient, would you consider a non-directed donation to a recipient selected by GUMC? * must provide value
Yes No2 If I am incompatible with my recipient (NOT a match), I am willing to participate in exchange.* must provide value
Yes No Sign to confirm choice for Question 1 (immediately above)* must provide value
( MB)
3 Even if I am compatible with my recipient, I am willing to consider a paired kidney exchange* must provide value
Yes No Sign to confirm choice for Question 2 (immediately above)* must provide value
( MB)
By my signature below and by clicking the "Submit" button to this questionnaire, I declare that I have read, understood, and agreed with the Live Kidney Donor Candidate Questionnaire Consents, and that all of the information entered into this questionnaire has been entered truthfully and accurately to the best of my ability.
By my signature below and by clicking "Submit", I consent to the following:
I consent to the release of my protected health information to the Organ Procurement and Transplantation Network.
I consent to the release of my protected health information to my primary care provider as indicated on the Living Kidney Donor Candidate Questionnaire.
I understand that MedStar Georgetown University Hospital is a teaching facility and part of my care, under the guidance of my physicians, may be conducted by Fellows, Residents and students.
I understand that my medical information, specimens and procedures, without revealing my identity, may be used for teaching and research activity.
I consent to taking photographs. The photographs may be taken only with the consent of my physician or surgeon and under such conditions as may be approved by him/her. The photographs shall be taken by my physician or by a competent photographer approved by my physician. These photographs shall be used for medical records only, unless in the judgment of my physician, medical research, education or science will benefit from their use. In that event, I agree that they may be used for such purposes, provided that my identity is not revealed by the photographs or by descriptive test accompanying them.
I consent to complete lab and other diagnostic testing to determine if I am a candidate for donation, including HIV, Hepatitis C, and Hepatitis B testing. Positive results from these tests are required to be reported to the Department of Health.
I understand that I may withdraw my consent at any time prior to the surgery.
I agree that I am proceeding with evaluation free of inducement and coercion.
I understand that I may be asked to provide a physical signature if I move forward with the evaluation. Sign to agree to the attachment: Living Kidney Donor Consent for Evaluation* must provide value
( MB)