MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work) (cell) Email : Emergency Contact name and # Race/Ethnicity: Citizenship Country of Origin Year of entry to US Highest education level Occupation Primary Language: Translator needed? Health Care Provider: Phone : Insurance: Group number: Phone: Who are you a donor for? Relationship? Why do you want to donate? Do you feel pressured / coerced in pursuing donation? What is your blood type? How tall are you? How much do you weigh? Marital status: Single Married Divorced Separated Widow/widower Does your significant other know that you are pursuing donation? Does he/she support you in this? Who do you live with? Do you have a support system to help you after surgery? Yes No Do you have any allergies to medication if yes which ones and how do they affect you? Yes No Do you have any allergies to foods? If yes, which ones? Yes No Do you have any allergies Latex? Page 1 of 5
Yes No Are you taking any medications? If yes please fill in below: Yes No Are you taking any herbs, vitamins or protein supplements? If yes please fill in below Name of Medicine Dose (mg) How many times a day? Family history: Yes No Mother living If deceased Cause Yes No Father living If deceased Cause Children: Number living Number deceased Siblings: Number living Number deceased Health status Cause of death Health status Cause of death Has anyone in your family ever had: If yes, who? How are they related to you? Yes No Heart attack? Yes No Stroke? Yes No High blood pressure? Yes No Diabetes? Yes No Cancer? What kind of cancer? Yes No Kidney Disease, Kidney Stones? Please describe Yes No Lupus, Sickle cell anemia? Past Medical History Yes No Have you ever been hospitalized for a medical or psychiatric disorder? When Why (what was the problem) Which Hospital Past Surgical history: Yes No Have you ever had surgery? When Why (what operation) Which Hospital Social history: Yes No Alcohol use? How much and how often do you drink? Yes No Illegal Drug use? If yes, what kind and how long? Yes No Treated with Rehab? Yes No Do you smoke cigarettes or chew tobacco? If yes how many packs per day? How many years smoking or chewing? If you smoked in the past, when did you stop? Page 2 of 5
Review of systems: (Check box if you now have or if you have ever had the following) 1. Constitutional / General: Yes No Fever or night sweats? Yes No Skin rash or ulcer? Yes No Weight loss? How much? Yes No Have you had any recent vaccinations? Yes No Do you feel tired all the time? Yes No Do you exercise? Yes No Do you have a history of cancer, infections or autoimmune diseases like Lupus, Scleroderma etc How many flights of stairs can you climb without stopping? 2. Neurological/Psychiatric: Yes No Do you have frequent headaches? Yes No Have you ever had a seizure? Yes No Dizziness or loss of consciousness? Yes No Anxiety disorder or depression? Yes No Numbness or tingling in arms/hands/legs/feet? Yes No Memory loss? Yes No attempted suicide? 3. HEENT: Yes No Ear problems? Yes No Do you wear any dentures? Yes No Nose bleeds? Yes No Do you have any loose teeth? Yes No Problems with your vision? Explain 4. Cardiovascular: 5. Respiratory: Yes No Heart murmur? Yes No Pneumonia? Yes No Heart attack? Yes No Asthma? Yes No Chest pain? Yes No Tuberculosis? Yes No Stroke? Yes No Positive Skin Test for TB (PPD, Tine Test)? Yes No Palpitations? Yes No Bronchitis? Yes No High blood pressure? Yes No Emphysema? Yes No Problems with circulation in legs? Yes No Have you ever coughed up blood? Yes No High Cholesterol? Yes No Blood clot in your legs or your lungs? 6. Gastrointestinal: Yes No Vomiting blood? Yes No Hemorrhoids? Yes No Ulcer? Yes No Blood on stool or in toilet bowl? Yes No Gallstones? Yes No Have you had a colonoscopy? Yes No Jaundice (Yellow skin or yellow eyes)? Yes No Change in color of stool? Yes No Hepatitis? Yes No Constipation for more than a few days? Yes No Pancreatitis? Yes No Diarrhea lasting more than a day? Yes No Diverticulitis? 7. Genito-urinary: Yes No Burning or pain when you pass urine? Yes No Blood or protein in urine? Yes No Trouble with your prostate? Yes No frequent urinary tract infections? Yes No kidney disease or kidney cancer Yes No Kidney Stones? Is yes, how many 8. Hematologic/lymph: 9. Musculoskeletal: Yes No Are your muscles weaker than before? Yes No Do you have a history of anemia? Yes No Joint pain or broken bones? Yes No Bruising or bleeding that does not stop easily? Yes No Arthritis Yes No Do you have any swollen glands? Yes No Do you have a history of blood clotting disorder? Page 3 of 5
10. Endocrine: 11. Breast (women and men) Yes No Do you have diabetes? Yes No Breast lumps or change in shape? Yes No Do you have high blood sugar? Yes No Nipple drainage? Yes No Do you have low blood sugar? Yes No Breast pain? Yes No Do you have thyroid problems? Yes No Skin change (rash, color, dimpling)? This section for women only: How old were you when you first had your period? When was your last menstrual period? How many times have you been pregnant? Yes No did you have diabetes while pregnant? Yes No Did you have hypertension while pregnant? Yes No Did you ever use birth control pills? Yes No Did you ever have a C-section? Yes No Have you had a tubal ligation? When was your last Pap smear? Results? When was your last Mammogram? Results? 13. High Risk Assessment : Yes No Have you had sex with a person known or suspected to have HIV, HBV, or HCV infections in the preceding 12 months? Yes No Are you a man who had sex with another man in the preceding 12 months? Yes No Are you a woman who had sex with a man with a history of MSM behavior in the preceding 12 months? Yes No Have you had sex in exchange for money or drugs in the last 12 months? Yes No Have you injected drugs by IV, IM, or subq route for nonmedical reasons in the preceding 12 months? Yes No Have you been in lockup, jail, prison, or a juvenile correctional facility for more than 72 hours in the preceding 12 months? Yes No Have you been newly diagnosed with or have been treated for syphilis, gonorrhea, Chlamydia, or genital ulcers in the preceding 12 months? Yes No Were you ever given human derived pituitary growth hormone? Yes No Have you ever received human-derived clotting factor for hemophilia or related clotting disorders? Yes No Have you had sex in the past 12 months with any person known or suspected of having viral hepatitis or HIV infections, or any person described in the above questions? Yes No having answered questions about medical conditions and behavioral risk factors, do you have any concerns that would make you think organ donation should not proceed? If yes, please explain your concerns. Yes No Have You traveled outside of the country in the last 3 years? If So where and when? **IMPORTANT INFORMATION FOR DONORS*** I acknowledge that it is illegal to buy and sell organs in the United States; I am not selling my kidney. My signature indicates that I understand the above and the information I have given is true to the best of my knowledge and I agree to have my picture taken and placed in the medical chart. Patient s Name (print) Date: Patient s Signature: Page 4 of 5
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Coordinator: Date: Surgeon: Date: Social Worker: Date: Nephrologist: Date: Donor Advocate: Date: Page 5 of 5