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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. 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:

Male Female

Phone:

Email Address:

Address:

City:

State:

Zip Code:

Okay to mail to your address?

Yes No

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?

Yes No Not Sure

What is your relationship with the intended recipient?

Sibling Parent Child Aunt/Uncle Cousin Spouse Mother/Father in law Brother/Sister in law Son/ Daughter in law Friend Social Media Other

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?

Yes No

Do you have any allergies to food or medications?

Yes No

If yes, please list:

Do you have a history of asthma?

Yes No

Have you ever been diagnosed with diabetes?

Yes No

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

Yes No

Do you have high blood pressure?

Yes No

Have you ever been diagnosed with kidney stones?

Yes No

If yes, when?

Do you have a history of cancer?

Yes No

If yes, when?

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

Do you take any prescribed medications?

Yes No

If yes, please list, including dosages and frequency:

Have you had abdominal surgery?

Yes No

If yes, please list procedure and date of procedure:

Have you ever been pregnant?

Yes No N/A

If yes, did you have Gestational Hypertension?

Yes No

If yes, did you have Gestational Diabetes?

Yes No

If yes, did you have Preeclampsia?

Yes No

If yes, did you have Eclampsia?

Yes No

Have you ever had a colonoscopy?

Yes No

If yes, when date of most recent?

Have you ever had a mammogram?

Yes No N/A

If yes, when was date of most recent?

Have you ever had a Pap smear?

Yes No N/A

If yes, when was date of most recent?

Have you ever been diagnosed with COVID-19?

Yes No

Have you ever been diagnosed with heart disease?

Yes No

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

Yes No

If yes, please explain:

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

Yes No

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?

Yes No

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?

Yes No

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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