Living Kidney Donor Screening Form

We appreciate your interest in living kidney donation and ask that you answer the following questions
to begin the process. Our staff will contact you within 10 business days when our medical team has made a decision about the next steps. If you have any questions or would prefer to complete this screening on the phone, please call us toll-free at (888) 822-7892. All information below will be kept secure and only used to determine if you meet initial requirements to be a living kidney donor.

Please fill out the form below. *Starred fields are required.

I would like to be a non directed donor (NDD). An NDD is a potential donor that does not have an intended recipient but wants to donate a kidney to anyone in need of a transplant

Yes

Intended Recipient Name(Required)

First Last

Non-Directed Donors, please enter 'n/a'.

Intended Recipient Date of Birth(Required)

Non-Directed Donors, please enter 'n/a'

Potential Donor Name(Required)

First Last

Relationship to Recipient(Required)

Birth Date (must be at least 18 yrs. old)(Required)

Complete Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Country of Citizenship(Required)

Were you born outside of the U.S.?

Yes

Have you ever lived outside of the U.S.?

Yes

Best phone number to reach you(Required)

Alternate Phone 1

Alternate Phone 2

Sex(Required)

Male

Female

Race(Required)

Marital Status(Required)

Single

Married

Divorced

Widowed

Employed

Yes

If employed, describe your work.

Weight(Required)

Height(Required)

Have you ever been diagnosed with any of the following:

Blood sugar problem or Diabetes(Required)

Yes

HIV(Required)

Yes

Hepatitis(Required)

Yes

Tuberculosis(Required)

Yes

Meningitis(Required)

Yes

High Blood Pressure(Required)

Yes

If yes, what year were you told you had high blood pressure?

If yes, list high blood pressure medication.

Allergies?

Have you ever had an allergic reaction to IV contrast dye?(Required)

Yes

Have you had a blood transfusion in the last 3 months?(Required)

Yes

How many kidney stones have you had in your life?(Required)

When was the last kidney stone?

How many urinary tract infections have you had in your life?(Required)

When was the last urinary tract infection?

Has a doctor ever told you that you had blood in your urine?(Required)

Yes

When was the last time a doctor told you about blood in your urine?

Have you ever had cancer?(Required)

Yes

If yes, please list type of cancer and approximate date.

Have you ever been told you have heart or lung disease?(Required)

Yes

If yes, please tell us the type of disease and approximate date.

If female, have you ever had a complication in pregnancy?

Yes

If yes, what kind of complication and when did it occur?

Please list all surgeries you’ve had and the approximate date(s).

Please please list any other health issues you've had that aren't listed above.

Does anyone in your family have Polycystic Kidney Disease?(Required)

Yes

Unknown

If yes, how are they related to you?

Who in your family has had kidney disease?

Who in your family has had high blood pressure?

Who in your family has had diabetes?

Please list any other major illnesses your family members have had. (ex: Cancer - mother)

Do you smoke any tobacco products now?(Required)

Yes

If yes, how many cigarettes per day?

If you do not smoke now, did you in the past?(Required)

Yes

If yes, when did you quit?

How many cigarettes per day?

How many drinks (glass of wine, 12 ounce beer, or 1.5 ounces of liquor) do you have per week?(Required)

Please list the illegal drugs you have used and the approximate dates.(Required)

Please list all medications (over the counter and prescribed) and vitamins you are taking with dosage, frequency and reason.(Required)

Have you ever been diagnosed with a psychiatric illness?

Yes

If yes, what kind?

Have you ever been diagnosed with depression?

Yes

If yes, when?

Have you ever attempted suicide?

Yes

If yes, how many times?

When?

How did you learn about donating a kidney to your loved one, or about living donation in general if you are a Non-Directed Donor?

from a Living Donor Champion

from the person that needs my kidney (recipient)

from Facebook group

from a UAB News article

from UAB Medicine advertising

from a community event

Thank you for considering the gift of life.