LIVING KIDNEY DONOR SCREENING QUESTIONNAIRE...REV Nicoletti Kidney Transplant Center 833 Chestnut...
Transcript of LIVING KIDNEY DONOR SCREENING QUESTIONNAIRE...REV Nicoletti Kidney Transplant Center 833 Chestnut...
920259 (REV. 12/18)
Nicoletti Kidney Transplant Center 833 Chestnut St, Suite 138 Philadelphia PA 19107 Phone 1-888-855-6649 Fax 215-503-4290
LIVING KIDNEY DONOR SCREENING QUESTIONNAIRE
For office use only: Date received BMI Donor MRN Declined Coordinator Comments:
Donor Name (Last, First) Date SSN Age DOB Gender Height Weight Blood type Marital status Race Caucasian African American Hispanic Asian Pacific OtherAddress: City State Zip Phone number: Home Cell Work Email Best way to contact Time Family/primary care physician’s name
Address: City State Zip Phone number Fax number
Recipient name: Relationship Listed for transplant no yes
Highest education level: None Grade school (1-8) High school or GED Bachelor’s degree Post-graduate degree Employment status: Full time Part time Occupation Are you on disability? Yes No. If yes, please state reason
920259 (REV. 12/18)
SECTION 1: PAST MEDICAL HISTORYHave you ever been treated for high blood pressure? No Yes Have you ever been told that you have heart disease? No YesDo you get frequent chest pains? No YesHave you ever had a heart attack/ bypass surgery/ angioplasty or stent placement? No YesHave you ever had a stress test within the last year? No YesHave you ever had a stroke? No YesIf answered yes to any of the above questions, please provide details Have you ever been treated for diabetes or high blood sugar including gestational diabetes during pregnancy? No YesIf yes, how many years ago were you first treated? Did you use diet pills insulin
SECTION 2: OTHER MEDICAL PROBLEMSCancer No YesLung No YesTuberculosis No YesAsthma No YesGastric/ intestinal issues No YesKidney Stone No YesPancreatitis No YesHepatitis No YesUrinary infection/cancer No YesBladder or kidney stones No YesSexually transmitted diseases No YesProtein in urine No YesNeurological disease No YesLupus No YesArthritis No YesHeadaches/ Migraines No Yes
Melanoma No YesCOPD/Emphysema No Yes
Pneumonia No YesHIV No Yes
Acid reflux/ ulcers No YesGallbladder stone/ disease No Yes
Liver disease No YesBleeding or clotting problems No Yes
Bladder infection/cancer No YesProstate Problems No Yes
Kidney disease No YesBlood in urine No Yes
Seizure No YesParalysis/ Stroke No Yes
Neuropathy No Yes
Obstetrics or gynecological problems (cancer/ fibroid/ endometriosis/ polycystic ovaries) No YesPregnancies/ miscarriages/ abortions No Yes
If answer to any of the above questions is yes, please provide details
SECTION 3: SURGICAL HISTORYList the surgical operations you have had in the past Date
920259 (REV. 12/18)
SECTION 4: MEDICATION LIST
SECTION 5: MEDICATION OR FOOD ALLERGIES List the medications or foods you are allergic to and the reaction you had when you took them:
SECTION 6: FAMILY HISTORYWhich of these diseases are found among any of your parents, brothers, sisters, extended family or children? diabetes high blood pressure kidney cancer cancer kidney disease coronary artery disease dialysis dependent transplant others
SECTION 7: PSYCHO-SOCIAL INFORMATIONHow often do you speak or see the recipient? Please tell us what motivated you to want to be considered as a living donor? Cigarette smoking never quit smoking at age # packs per day
started smoking at age still smoking # packs per day Alcohol never drink socially past heavy drinker present heavy drinker
Details Intravenous drug use never quit within past year quit over a year ago still using
Details Other illicit/ recreational drug use never quit within past year quit over a yr ago still using
Details Have you ever been treated for substance use? No Yes
If yes, when and where? Have you ever been diagnosed with depression, anxiety, schizophrenia, bipolar disorder, personality disorders? No Yes
If yes, please provide details Have you ever taken medications and/or received therapy because of depression, anxiety or other mental illness or emotional problems? No Yes
If yes, please provide details, including provider of treatment
Have you ever had thoughts about hurting yourself or attempted suicide? No Yes If yes, please provide details