Kidney Transplant Evaluation Form

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Iowa Methodist Medical Center
Transplant Center
1215 Pleasant Street, Suite 506
Des Moines, IA 50309
515-241-4044 Phone
515-241-4100 Fax
Iowa Methodist Transplant Center
Kidney Recipient Health History Form
Personal Information
Full Name: _______________________________________________
Date of Birth: ____________________
□ Male
□ Female
Social Security Number: _________________________
Mailing Address: ___________________________________________________________________
City: ____________________ State: ______________________ Zip Code: _____________________
Home Telephone: ________________ Cell phone: _________________ Work phone: _____________
Email address: _____________________________________________________________________
Race: _______________ Place of Birth: ____________________ Are you a US Citizen?
□ Yes
□ No
Advance Directives
What is your CODE status?
FULL
or
Are you willing to accept blood products?
DNR (Do Not Resuscitate) (please circle one)
_____ Yes _____ No
Do you have a Durable Power of Attorney? _____ Yes* _____ No
Do you have a Living Will?
_____ Yes* _____ No
*Please be prepared to provide a copy.
Emergency Contacts
Name: ____________________________________ Telephone Number: _______________________
Name: ____________________________________ Telephone Number: _______________________
Name: ____________________________________ Telephone Number: _______________________
Name: ____________________________________ Telephone Number: _______________________
Health Care Providers Please provide a list of all of your healthcare providers:
Kidney Doctor:
___________________________________
Family Doctor:
___________________________________
Heart Doctor:
___________________________________
Diabetes Doctor:
___________________________________
Other Doctor:
___________________________________
Allergy History
Medication allergies: _______________________________________________________________________
Food or Environmental allergies: ______________________________________________________________
Medical History
Please check if you have any of the following conditions/symptoms:
___ Diabetes
___ Peripheral Vascular Disease
___ Bladder problems
___ High blood pressure
___ Hearing difficulties
___ Kidney infections
___ High cholesterol
___ Vision difficulties
___ Kidney stones
___ Lung disease
___ Thyroid problems
___ Liver disease
___ Sexually transmitted disease
___ Bleeding disorder
___ Chronic pain
___ Chicken pox
___ Sleeping difficulties
___ Depression/Anxiety
___ Shingles
___ Cancer
___ Blood transfusions
___ Heart attack
___ Teeth or gum problems
___ Previous transplant
___ Stroke
___ Seizure Disorder
Dialysis Start Date: __________
Immunization and Preventative Health History
Tetanus _______
Pneumonia _______
Dental Exam _________
Surgeries/Injuries
Flu _______
Eye Exam_________
(Women Only: Mammogram _________
When did you last have the following:
Hepatitis A _______
Hepatitis B_______
Colonoscopy _________
Pap smear _________
Please list any surgeries/injuries:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Social History
Marital Status:
□ Single
□ Married
□ Divorced
□ Widowed
Spouse/Significant Other’s name: ________________________________
Telephone:_______________
Maiden Name or any other name under which records may be kept:__________________________
What is your highest level of education completed________________________________________
Are you currently working? □ Yes □ No
If Yes, □ Full time or □ Part time?
Occupation_____________________________Employer___________________________________
Tobacco Use: _____No _____ Yes, how much/how long____________________________________________
Alcohol Use: _____ No_____ Yes, how much/how often____________________________________________
Recreational Drug Use: _____ No_____ Yes, how much/how often____________________________________
Can you perform your daily activities independently? _____ No_____ Yes
If No, please explain __________
__________________________________________________________________________________________
Do you exercise regularly? ___________________________________________________________________
Family History
Age
Current Health Status/Cause of Death_____
Father
________
___________________________________________
Mother
________
___________________________________________
Spouse
________
___________________________________________
□ Brother or □ Sister
________
___________________________________________
□ Brother or □ Sister
________
___________________________________________
□ Brother or □ Sister
________
___________________________________________
□ Brother or □ Sister
________
___________________________________________
□ Brother or □ Sister
________
___________________________________________
□ Male or □ Female Child
________
___________________________________________
□ Male or □ Female Child
________
___________________________________________
□ Male or □ Female Child
________
___________________________________________
□ Male or □ Female Child
________
___________________________________________
(Please indicate if you or other family members are adopted.)
Do you know of anyone who may be interested in donating a kidney to you? _____ Yes _____ No
Have you ever received a blood transfusion? _______ Yes _______ No. If you answer yes to this question
when did you receive blood and how many units did you receive__________________________
Additional
Is there any additional information that you feel is important for us to know about your medical history or
current situation?
__________________________________________________________________________________________
__________________________________________________________________________________________
Please bring the following to your evaluation:
 Informed Consent
 Completed Kidney Recipient Health History Form
 Insurance Cards
 List of Medications
 Copy of Durable Power of Attorney and/or Living Will
(The Transplant Center will make copies for you if necessary.)
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