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 Lothian.livingkidneydonation@nhs.net. 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