Iowa Methodist Transplant Center
Iowa Methodist Medical Center
1215 Pleasant Street, Suite 506
Des Moines, IA 50309
Phone: 515-241-4044
Fax: 515-241-4100
Iowa Methodist Transplant Center
Living Donor Health History Form
Personal Information
Full Name: _______________________________________________
Date of Birth: ____________________
□ Male □ Female
Social Security Number: _________________________
Mailing Address: ___________________________________________________________________
City: ____________________ State: ______________________ Zip Code: _____________________
Home phone: ________________ Cell phone: _________________ Work phone: _____________
Email address: _____________________________________________________________________
Race: ___________________ Place of Birth: ___________________ Are you a US Citizen? □ Yes □ No
Donor For: _________________________ Relationship: _______________________________
Advance Directives
What is your CODE status?
FULL or
DNR (do not resuscitate) (please circle one)
Are you willing to accept blood products?
_____ 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:
Family Doctor: ___________________________________
Other: __________________________________________
Other: __________________________________________
Immunization/Procedure History
When did you last have if applicable?
Eye Exam_______ Colonoscopy ______ Women Only: Mammogram _______
Pap smear _______
Medical History
Please check if you have any of the following conditions/symptoms:
___ Diabetes
___ Peripheral Vascular Disease
___ Bladder problems
___ High blood pressure
___ Stroke
___ Kidney infections/stones
___ High cholesterol
___ Vision difficulties
___ Seizure Disorder
___ Lung disease
___ Hearing difficulties
___ Liver disease
___ Sexually Transmitted Disease
___ Bleeding disorder
___ Thyroid problems
___ Chicken pox
___ Sleeping difficulties
___ Anxiety
___ Shingles
___ Cancer
___ Depression
___ Heart attack
___ Teeth or gum problems
___ Chronic pain
Height: _________________
Weight: ________________
Other: ___________________
Surgeries/Injuries
Please list any surgeries/injuries:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Allergy History
Medication allergies: _______________________________________________________________________
Food or Environmental allergies: _____________________________________________________________
Medication
Please List any medications taken including herbal medications.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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: __________________________
Are you currently working? □ Yes □ No
If Yes, □ Full time or □ Part time?
Occupation_____________________________Employer___________________________________
Do you carry medical insurance: □ Yes □ No
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____________________________________
Significant weight loss or gain? _____ No _____ Yes If Yes, how much: ______________________________
Current blood pressure if known: ______________________
Can you perform your daily activities independently? _____ No_____ Yes
If No, please explain __________
__________________________________________________________________________________________
Do you exercise regularly? ___________________________________________________________________
Family History
Age
Father
Current Health Status/Cause of Death_____
________
Mother
___________________________________________
________
___________________________________________
Spouse
________
___________________________________________
□ 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*
Additional
Why are you pursuing kidney donation?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please bring the following to your evaluation:

Informed Consent

Completed Kidney Recipient Health History Form

List of Medications

Copy of Durable Power of Attorney and/or Living Will
(The Transplant Center will make copies for you if necessary.)