MGTI Living Kidney Donor Questionnaire

THIS SURVEY IS CURRENTLY INACTIVE.

PLEASE VISIT WWW.MEDSTARGEORGETOWN.ORG/LIVINGKIDNEYDONOR TO COMPLETE THIS HEALTH QUESTIONNAIRE

Thank you for contacting the MedStar Georgetown Transplant Institute’s Living Kidney Donor Program! We encourage you to read this entire page before starting the questionnaire.

Please review our attached welcome letter. It will provide you with a general outline of what to expect during your living donor evaluation process. It will also be emailed to you once you complete the questionnaire. There are many steps involved to ensure the safety and well-being of both you and your recipient.

Your information will not be reviewed until you sign and click "Submit" button on the final page. All information disclosed in this questionnaire is confidential.

Please fill in the blanks below. Your information will be saved while completing the questionnaire. You can return to the questionnaire at any time by coming back to this page. Click the blueReturning? arrow in the top right corner of this page and enter your Return Code. It will be necessary for you to open a PDF file to complete your Consent for Evaluation.

DO NOT SUBMIT MULTIPLE COPIES OF THIS QUESTIONNAIRE. If you lose your Return Code, please call or email the donor liaison to retrieve it.

If you do not have an email address, please call the donor liaison for assistance.

Please give yourself 20-40 minutes to complete the questionnaire regarding your medical and personal history. If you are interested in donating to a specific person, please have your recipient’s name and date of birth ready before starting.

At any time during this process you are free to change your mind about proceeding with living donation. We ask that you inform of us of this decision.

When you are ready to begin, click "Next Page >>" below.

Thank you again for contacting the MedStar Georgetown Transplant Institute and for pursuing this wonderful gift! Please do not hesitate to call or email us if you need additional assistance.

Please note that THIS QUESTIONNAIRE IS FOR KIDNEY DONATION ONLY, please contact the living donor liaison for assistance with liver donation questions at 202-444-3714 or 202-444-4559.

Important contact information:
Donor Liaison: 202-444-3714 or JonesL2@gunet.georgetown.edu
General Transplant Institute Office: 202-444-3700 or 1-800-492-5538
Transplant Institute Fax: 202-444-0899 or 877-680-8193 Attention: LD Coordinator

Please open and read the attachment, "What to Expect as a Kidney Donor."

Attachment:What to Expect During the Donation Process.pdf

Legal First Name

* must provide value

Middle Name

Last Name

* must provide value

Suffix

Date of Birth

* must provide value

M-D-Y

Email Address

* must provide value

Do you live outside the United States?

* must provide value

Yes

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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: "______"

Demographic Information

Hello, ______ ______, thank you for beginning the Living Kidney Donor Questionnaire.

Today's date

* must provide value

M-D-Y

Today's date (auto)

Y-M-D H:M

Age

View equation

Sex

* must provide value

Male Female

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Social Security Number

Foreign National Number

Race

* must provide value

Caucasian

African-American

Hispanic

Asian-Pacific

Other

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Other Race

Mother's Race

* must provide value

Caucasian

African-American

Hispanic

Asian-Pacific

Other

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Other Race

Father's Race

* must provide value

Caucasian

African-American

Hispanic

Asian-Pacific

Other

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Other Race

Primary Language (if other than English)

Would you like an interpreter?

Yes No

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Citizenship

* must provide value

US citizen

Permanent resident / Green card

Other

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Citizenship other

Present Relationship Status

* must provide value

Married

Domestic Partner

Single

Divorced

Widowed

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Present Employment Status

* must provide value

Work full-time

Work part-time

Unemployed

Self-Employed

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Emergency Contact Name

* must provide value

Emergency Contact's Sex

* must provide value

Male Female

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Emergency Contact's Phone Number

* must provide value

Emergency Contact Relationship

* must provide value

Your Permanent HOME Address (required)

Street Line 1

Street Line 2

City

State/Province

Zip Code

Country

International Home Phone Number

International Cell Phone Number

International Work Phone Number

Do you give MGTI your permission to email you your health information?

Yes No

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Preferred Phone

Home Cell Work

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Do you give MGTI your permission to leave your health information in a voicemail to your preferred phone?

Yes No

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Do you have a temporary US address?

Yes No

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Your Temporary US Address

Street

City

State

Zip Code

Home Phone

Cell Phone

Fax Number

My preferred contact route is

Home Phone Cell Phone Work Phone .

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I give permission for my personal health information to be shared with me via

Home phone via voicemail

Cell phone via voicemail

Your WORK address

Employer

Work Street

Work City

Work State

Work Zip Code

Work Phone

Work Fax

FAMILY Doctor

Date of last visit

M-D-Y

Physician's Name

Office Street

Office City

Office State

Office Zip

Office Phone

Office Fax Number

I am interested in donating my kidney to:

First Name

* must provide value

Middle Initial

Last Name

* must provide value

Suffix

Date of Birth

M-D-Y

Age

View equation

Sex

Male Female

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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

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Specify Recipient

I have never met the recipient

I met the recipient on a website

I do not have an intended recipient

Other

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Specify Relationship

Specify Website

Please tell us if you have had any of the following

High Blood Pressure/Hypertension

* must provide value

Yes, now Yes, in the past Never

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Heart Attack

* must provide value

Yes, now Yes, in the past Never

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Chest Pain with Exercise

* must provide value

Yes, now Yes, in the past Never

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Stroke or TIA

* must provide value

Yes, now Yes, in the past Never

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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

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Diabetes

* must provide value

Yes, now Yes, in the past Never

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Gestational Diabetes

* must provide value

Yes, now Yes, in the past Never

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How is your Diabetes controlled?

Miscarriage

* must provide value

Yes, now Yes, in the past Never

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Please Specify How Many

Addiction

* must provide value

Yes, now Yes, in the past Never

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Please Specify

Alcohol Drugs Other

If Other, Please Specify

Date of Last Use

Cancer

* must provide value

Yes, now Yes, in the past Never

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Specify When

Specify Cancer Type and Location

Specify Cancer Treatment

Mental Health Issues

* must provide value

Yes, now Yes, in the past Never

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Liver Problems

* must provide value

Yes, now Yes, in the past Never

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Hepatitis

* must provide value

Yes, now Yes, in the past Never

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HIV

* must provide value

Yes, now Yes, in the past Never

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Kidney Disease

* must provide value

Yes, now Yes, in the past Never

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Please Specify Type of Kidney Disease

Polycystic Kidney Disease Other

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Please Provide Disease Details

Kidney Stones

* must provide value

Yes, now Yes, in the past Never

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Specify When and How Many

Seizures

* must provide value

Yes, now Yes, in the past Never

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Suicide Attempts

* must provide value

Yes, now Yes, in the past Never

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Abnormal PAP results

* must provide value

Yes No N/A

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If Yes, Please Specify

Abnormal Mammogram

* must provide value

Yes No N/A

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If Yes, Please Specify

Abnormal PSA

* must provide value

Yes No N/A

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If Yes, Please Specify

Abnormal Colonoscopy

* must provide value

Yes No N/A

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If Yes, Please Specify

Please list any other medical conditions that you currently have or had in the past that were not mentioned in the list above.

First Condition

Second Condition

Third Condition

Fourth Condition

Fifth Condition

List any surgical operations you have had in the past.

Have you ever had surgery in the past?

* must provide value

Yes, and I will list them below

No, I have never had surgery

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First Surgery

Second Surgery

Third Surgery

Fourth Surgery

Fifth Surgery

If you have had more than 5 surgeries, please list them here

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List the medications you are taking now, including prescriptions, over-the-counter, herbs, or supplements.

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

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First Medication

Second Medication

Third Medication

Fourth Medication

Fifth Medication

Sixth Medication

Seventh Medication

Eighth Medication

Ninth Medication

Tenth Medication

Eleventh Medication

Twelfth Medication

Thirteenth Medication

Fourteenth Medication

Fifteenth Medication

If you take more than 15 medications, please list them here

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List the medications or foods you are allergic to and the reaction you had when you took them

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

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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

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Are you allergic to Latex?

Yes No

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Please specify your reaction

Are you allergic to Shellfish?

Yes No

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Please specify your reaction

Are you allergic to X-ray or contrast dye?

Yes No

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Please specify your reaction

Does anyone in your family have any of the following

Diabetes

* must provide value

Yes No

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Please specify your relationship with the family member

Kidney Disease

* must provide value

Yes No

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Please specify your relationship with the family member

Please Specify Type of Kidney Disease

Polycystic Kidney Disease Other

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Please Provide Kidney Disease Details

High Blood Pressure/Hypertension

* must provide value

Yes No

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Please specify your relationship with the family member

Cancer

* must provide value

Yes No

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Please specify your relationship with the family member

Please complete the following psycho-social information

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

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Please tell us what motivated you to want to be considered as a living donor

* must provide value

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What personal values led you to register today?

* must provide value

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What is your present (or past) occupation?

* must provide value

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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 time

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Do you currently have health insurance?

* must provide value

Yes No

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Who will take care of you at home after the surgery?

* must provide value

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 Times

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Have you previously donated bone marrow or stem cells?

* must provide value

Yes No

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Your highest educational degree

* must provide value

Have you ever travelled or lived outside of the US?

* must provide value

Yes No

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If so, where and for how long?

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Do you or have you ever smoked cigarettes?

* must provide value

Never

Yes, in the past

Yes, now

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How many packs per day and for how long?

How long ago did you quit?

Do you or have you ever used other tobacco products?

* must provide value

Never

Yes, in the past

Yes, now

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What type of tobacco?

How much and how often?

Date of Last Use

M-D-Y

Do you or have you ever drank alcohol?

* must provide value

Never

Drink Socially

Past Social Drinker

Present heavy drinker

Past heavy drinker

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How many and how often

Date of last use

M-D-Y

Do you or have you ever used intravenous drugs?

* must provide value

Never

Quit within past year

Quit over a year ago

Still using

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Type of Drug

How much and how often

Date of last use

M-D-Y

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

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Type of Drug

How much and how often

Date of last use

M-D-Y

Have you ever been treated for substance abuse?

* must provide value

Yes No

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When and where were you treated?

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Have you ever been involved in legal issues involving law enforcement? (including DUI/DWI)

* must provide value

Yes No

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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

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When and where?

What is your Religion

* must provide value

Will you accept blood products?

* must provide value

Yes No, I do not accept blood products because of my religious beliefs

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Have you ever taken medications to treat depression, anxiety, or other mental illness or emotional problems?

* must provide value

Yes No

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Please list the name of the medication, date of last use, and diagnosis

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Have you had a PPD test (Tuberculosis Skin Test) in the last 90 days?

* must provide value

Yes No

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If so, when?

M-D-Y

How did you hear about the MedStar Georgetown Transplant Insitiute?

* must provide value

Please specify how you heard

Which of these have significantly bothered you lately?

Any metal in your body

* must provide value

Yes No

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Specify Where

Any piercings

* must provide value

Yes No

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Specify Where

Tooth or gum problems

* must provide value

Yes No

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Chest pain

* must provide value

Yes No

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Fluttering in chest

* must provide value

Yes No

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Fainting spells

* must provide value

Yes No

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Shortness of breath

* must provide value

Yes No

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Wheezing

* must provide value

Yes No

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Bloody urine

* must provide value

Yes No

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Cloudy urine

* must provide value

Yes No

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Sores/ discharge from genitals

* must provide value

Yes No

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Abnormal menstrual bleeding

* must provide value

Yes No

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Breast tenderness

* must provide value

Yes No

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Nipple discharge

* must provide value

Yes No

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Anxiety

* must provide value

Yes No

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Depression

* must provide value

Yes No

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Hallucinations

* must provide value

Yes No

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Claustrophobia

* must provide value

Yes No

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Low Thyroid

* must provide value

Yes No

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What is your weight? (In Pounds)

* must provide value

What is your height? (Feet)

* must provide value

What is your height? (Inches)

* must provide value

Please open and read the entire attached consent form

Attachment:LKD Consent for Evaluation.pdf

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!

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 No

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If I am incompatible with my recipient (NOT a match), I am willing to participate in exchange.

* must provide value

Yes No

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Sign to confirm choice for Question 1 (immediately above)

* must provide value

Add signature

Even if I am compatible with my recipient, I am willing to consider a paired kidney exchange

* must provide value

Yes No

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Sign to confirm choice for Question 2 (immediately above)

* must provide value

Add signature

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

Add signature

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.