Please open and read the attachment, "What to Expect as a Kidney Donor."
1 Legal First Name
* must provide value
2
3 Last Name
* must provide value
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
Now Y-M-D H:M
2 View equation
3 Male Female
4
Must be formatted (xxx-xx-xxxx)
5 Caucasian
African-American
Hispanic
Asian-Pacific
Other
6 Mother's Race
* must provide value
Caucasian
African-American
Hispanic
Asian-Pacific
Other
7 Father's Race
* must provide value
Caucasian
African-American
Hispanic
Asian-Pacific
Other
8 Primary Language (if other than English)
9 Would you like an interpreter?
Yes No
10 Citizenship
* must provide value
US citizen
Permanent resident / Green card
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 Female
16 Emergency Contact's Phone Number
* must provide value
17 Emergency Contact Relationship
* must provide value
Your Permanent HOME Address (required)
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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
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 No
18
19
20 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
22
If you do not have a home telephone number, please type your best contact number
23
24
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
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30 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)
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Today M-D-Y
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38 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)
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1 First Name
* must provide value
If you do not have an intended recipient, please type "N/A" into this field
2
3 Last Name
* must provide value
If you do not have an intended recipient, please type "N/A" into this field
Jr. Sr. II III IV
4
Today M-D-Y
5 View equation
6 Male Female
8 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"
I have never met the recipient
I met the recipient on a website
I do not have an intended recipient
Other
1 High Blood Pressure/Hypertension
* must provide value
Yes, now Yes, in the past Never
2 Heart Attack
* must provide value
Yes, now Yes, in the past Never
3 Chest Pain with Exercise
* must provide value
Yes, now Yes, in the past Never
4 Stroke or TIA
* must provide value
Yes, now Yes, in the past Never
5 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 Never
7 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
9 Addiction
* must provide value
Yes, now Yes, in the past Never
10 Cancer
* must provide value
Yes, now Yes, in the past Never
Specify Cancer Type and Location
11 Mental Health Issues
* must provide value
Yes, now Yes, in the past Never
12 Liver Problems
* must provide value
Yes, now Yes, in the past Never
13 Hepatitis
* must provide value
Yes, now Yes, in the past Never
14 Yes, now Yes, in the past Never
15 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 Never
18 Suicide Attempts
* must provide value
Yes, now Yes, in the past Never
Abnormal PAP results
* must provide value
Yes No N/A
Abnormal Mammogram
* must provide value
Yes No N/A
Abnormal PSA
* must provide value
Yes No N/A
Abnormal Colonoscopy
* must provide value
Yes No N/A
20
Please leave this field blank if you do not have any other conditions
21
Please leave this field blank if you do not have any other conditions
22
23
24
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
Please include the procedure as well the month and year of the operation in the box above
2
Please include the procedure as well the month and year of the operation in the box above
3
Please include the procedure as well the month and year of the operation in the box above
4
Please include the procedure as well the month and year of the operation in the box above
5
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
Please include name, dose, and frequency of the medication in the box above
2
Please include name, dose, and frequency of the medication in the box above
3
Please include name, dose, and frequency of the medication in the box above
4
Please include name, dose, and frequency of the medication in the box above
5
Please include name, dose, and frequency of the medication in the box above
6
Please include name, dose, and frequency of the medication in the box above
7
Please include name, dose, and frequency of the medication in the box above
8
Please include name, dose, and frequency of the medication in the box above
9
Please include name, dose, and frequency of the medication in the box above
10
Please include name, dose, and frequency of the medication in the box above
11
Please include name, dose, and frequency of the medication in the box above
12
Please include name, dose, and frequency of the medication in the box above
13
Please include name, dose, and frequency of the medication in the box above
14
Please include name, dose, and frequency of the medication in the box above
15
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
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 time
6 Do you currently have health insurance?
* must provide value
Yes No
7 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 Times
9 Have you previously donated bone marrow or stem cells?
* must provide value
Yes No
10 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 No
12 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
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
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
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
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 No
20 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
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 beliefs
23 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
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
2 Any piercings
* must provide value
Yes No
3 Tooth or gum problems
* must provide value
Yes No
4 Chest pain
* must provide value
Yes No
5 Fluttering in chest
* must provide value
Yes No
6 Fainting spells
* must provide value
Yes No
7 Shortness of breath
* must provide value
Yes No
8 Wheezing
* must provide value
Yes No
9 Bloody urine
* must provide value
Yes No
10 Cloudy urine
* must provide value
Yes No
11 Sores/ discharge from genitals
* must provide value
Yes No
12 Abnormal menstrual bleeding
* must provide value
Yes No
13 Breast tenderness
* must provide value
Yes No
14 Nipple discharge
* must provide value
Yes No
15 Anxiety
* must provide value
Yes No
16 Depression
* must provide value
Yes No
17 Hallucinations
* must provide value
Yes No
18 Claustrophobia
* must provide value
Yes No
19 Low Thyroid
* must provide value
Yes No
20 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 No
2 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
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
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