Purpose: helps determine suitability for kidney donation
Preliminary questionnaire (short, basic medical history questions)
Donor Disclosure and Medical and Social History questionnaire (in-depth questionnaire)
Donor Disclosure and Medical and Social History Questionnaire
*Note: You can fill out the form or have someone fill out the form on your behalf
Demographic Information
Primary care provider information (family doctor or nurse practitioner)
Donor disclosure form (to acknowledge that you understand buying and selling organs is considered illegal and that you have not received any financial incentives for donating a kidney)
Questions about the intended recipient for donation and why you want to donate a kidney
Type of work you do, if you are able to take time off to recover after surgery, support at home or who is available to help you during recovery
Consent to receiving blood products (if needed during surgery and recovery)
Questions about historical organ or blood donation (if applicable)
Physical activity level
Ongoing health concerns
History of major illness/admissions to hospitals/past surgical procedures (previous history of reactions to anesthesia)
Medication history/allergies/active infections
Medical conditions/history of chronic diseases/communicable diseases (including Tuberculosis)
Mental Health history
Past history with blood transfusions (if applicable)
Pregnancy history/plans for future pregnancies
History of certain diagnostic tests: Pap smears, mammograms, prostate exams/bloodwork
Social history (including smoking, alcohol use, recreational drug use, sexual health, exposure to communicable diseases,
recent history of tattoos and body piercings)
Brother's Keeper