Live Kidney Donor Healthcheck Questionnaire

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Live Kidney Donor Healthcheck Questionnaire
Please complete this form and return by post to Living Donor Transplant Co-ordinators,
Transplant Unit, Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SU or via
email to [email protected] If there are any questions you are unable to
answer, we can discuss them at your clinic visit. We will also contact your GP during the
assessment process.
Section 1 Registration details:
Name and Title
...................................................................................
Date of Birth
............/............../............
Address
....................................................................................
Postcode
....................................................................................
....................................................................................
................. ..................
.............................
Tel No
Home
..................................................................
Work
..................................................................
Mobile
..................................................................
GP
.....................................................................................
....................................................................................
.....................................................................................
.....................................................................................
Who do you wish to donate a kidney to? Please circle and complete:
1. Relative/Friend:
Name:
Date of birth:
Relationship :
Have you discussed this with the potential recipient? Yes / No
Your immediate family? Yes / No
Or
2. Altruistic (to someone you don’t know on the national transplant waiting list)
Have you discussed this with your immediate family? Yes / No
Where did you first hear about live kidney donation? Please circle:
Hospital / Renal Unit /GP
Potential recipient
Family / friends
Media – TV / Newspaper / Radio / Internet
Other:
Section 2 – Healthcheck Questions: Please tick appropriate box:
Yes
1.
2.
Are you fit and well?
Do you take any medication prescribed by your doctor?
If yes:
3.
Have you a medical history of cancer; heart disease;
respiratory problems; any major operation? Have you
ever been seen by a skin specialist?
If yes:
4.
Have you ever had kidney problems/urine
infections/kidney stones?
If yes:
5.
6.
7.
Have you ever received a blood transfusion?
Have you ever been a blood donor?
Have you ever been refused as a blood donor?
Can you provide further details to the above?
8.
Have you ever required psychiatric care (including
medication or treatment for depression)?
If yes:
9.
Do you smoke? If yes; how many per day?
No
Approximately how much alcohol do you drink per week?
10.
11.
12.
Signed:
What is your height and weight (approx if unknown)
Height:
Weight:
Are you up-to-date with routine screens? For example,
cervical and breast screening for women, bowel screening
for over-50s
When did you last have your blood pressure checked?
Print name:
Date:
Don’t
know
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