Living Donor Online Referral

Living kidney donors are saving lives by helping people with kidney failure get a new kidney faster. Whether it’s a family member, friend or complete stranger as the recipient, by becoming a living donor you have the opportunity to help someone waiting for a kidney.

If you are interested in learning more about becoming a living donor and to find out if you are an eligible donor, please complete this questionnaire to request an appointment with a member of our team. At this time, only the demographic information is required. All other questions are optional, however, helpful for the initial appointment.

The following collected information is protected health information within our secure platform.

Patient Demographics

Name (Legal):

Date of Birth:

Height:

Weight:

Assigned Gender:

MaleFemale

Phone:

Email Address:

Address:

City:

State:

Zip Code:

Okay to mail to your address?

YesNo

Mailing Address (if different from above):

Donor Info

Do you wish to donate to:

Someone Specific

Anyone in Need

If someone specific, name of the person you would like to donate to:

Is the intended recipient a patient at LVHN Transplant?

YesNoNot Sure

What is your relationship with the intended recipient?

SiblingParentChildAunt/UncleCousinSpouseMother/Father in lawBrother/Sister in lawSon/ Daughter in lawFriendSocial MediaOther

If relationship is other, please specify:

Have you ever used LVHN services?

Yes

No

Health Questions

Do you have any religious beliefs that might prevent you from receiving a blood transfusion?

YesNo

Do you have any allergies to food or medications?

YesNo

If yes, please list:

Do you have a history of asthma?

YesNo

Have you ever been diagnosed with diabetes?

YesNo

Do you have a family history of diabetes (parents, siblings or grandparents)?

YesNo

Do you have high blood pressure?

YesNo

Have you ever been diagnosed with kidney stones?

YesNo

If yes, when?

Do you have a history of cancer?

YesNo

If yes, when?

If yes, what was your treatment (surgery, radiation, chemotherapy)?

Do you take any prescribed medications?

YesNo

If yes, please list, including dosages and frequency:

Have you had abdominal surgery?

YesNo

If yes, please list procedure and date of procedure:

Have you ever been pregnant?

YesNoN/A

If yes, did you have Gestational Hypertension?

YesNo

If yes, did you have Gestational Diabetes?

YesNo

If yes, did you have Preeclampsia?

YesNo

If yes, did you have Eclampsia?

YesNo

Have you ever had a colonoscopy?

YesNo

If yes, when date of most recent?

Have you ever had a mammogram?

YesNoN/A

If yes, when was date of most recent?

Have you ever had a Pap smear?

YesNoN/A

If yes, when was date of most recent?

Have you ever been diagnosed with COVID-19?

YesNo

Have you ever been diagnosed with heart disease?

YesNo

Have you ever been diagnosed with a psychiatric diagnosis or been hospitalized for psychiatric reasons?

YesNo

If yes, please explain:

Do you smoke cigarettes, vape, or use smokeless tobacco, now or in the past?

YesNo

If yes, please specify which form:

If yes, when did you start?

If yes, how much do you/did you smoke?

When did you quit, if applicable?

Do you use recreational drugs, including marijuana, now or in the past?

YesNo

If yes, what drug(s) have you or do you use?

If yes, when did you start?

If yes, how much do you/did you use?

If yes, have you ever been to any treatment, rehab, or detox for drug or alcohol use?

When did you quit, if applicable?

Do you drink alcohol, now or in the past?

YesNo

If yes, how many drinks do you have on average per week?

If yes, how often do you have 6 or more drinks on one occasion?

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