Living Donor Screener Preview

Do you currently take any medications, vitamins, or herbal supplements (including those taken regularly or as-needed)?

• Yes
• No

Do you have any medication allergies?

• Yes
• No

Are you allergic to any of the following?

• Betadine
• Chlorhexidine
• Contrast (X-Ray Dye)
• Iodine
• Latex
• Rabbits
• Shellfish
• Tape
• None of the above

Do you take medications to control blood pressure?

• Yes
• No

Do you smoke cigarettes?

• Yes
• No
• Used to

Do you smoke tobacco?

• Yes
• No
• Used to

How often do you consume alcohol?

• Never
• Once or twice per year
• Once or twice per month
• Once or twice per week
• Every day (1–2 drinks)
• Every day (more than 2 drinks)

Do you have a history of alcohol abuse?

• Yes
• No

Do you use recreational drugs?

• Yes
• No
• Used to

Which best describes your current physical activity level?

• I can participate in strenuous sports (swimming, singles tennis, football, basketball, skiing).
• I can participate in moderate activities (golf, doubles tennis, dancing, throwing a baseball).
• I can climb 2 flights of stairs without stopping.
• I can climb 1 flight of stairs or less.
• I can walk 1 block or less before stopping.
• I am short of breath at rest.
• I am wheelchair bound.
• I am unable to perform physical activity due to severe back, joint, or neck pain.

How often do you exercise?

• I do not exercise regularly.
• Once per week
• Twice per week
• Three times per week
• More than three times per week

Do you get chest pain at rest?

• Yes
• No

Do you get chest pain with activity (e.g., walking or climbing stairs)?

• Yes
• No

Have you had a stress test?

• Yes
• No

Have you had a cardiac catheterization?

• Yes
• No

Do you currently have, or have you ever had, any of the following?

• Airway and/or lungs condition
• Blood disorder (abnormal bruising, bleeding, or clotting)
• Cancer, chemotherapy, and/or radiation therapy
• Diabetes, thyroid, adrenal, and/or other endocrine disorder
• Digestive tract and/or liver disease
• Heart and/or circulatory system condition
• Immune-mediated disease
• Infection
• Kidneys and/or bladder condition
• Men's health condition
• Mental well-being condition
• Muscles, bones, and/or joints condition
• Neurological deficit (brain and/or spine)

Do any family members have any of the following?

• Kidney disease
• Polycystic kidney disease (PCKD)
• Kidney stones
• Diabetes
• Sickle cell
• Cancer
• High blood pressure
• Heart disease
• Lupus
• Blood clots
• Mental illness
• High cholesterol or high triglycerides (hyperlipidemia)

Have any family members died suddenly before age 50?

• Yes
• No

What is your blood type?

• A
• B
• AB
• O
• Unknown

Would you accept a blood transfusion if necessary?

• Yes
• No

Have you had any of the following in the past 12 months?

• Sex with a person known or suspected to have HIV, HBV, or HCV
• Man who has had sex with another man
• Sex in exchange for money or drugs
• Sex with a person who had sex in exchange for money or drugs
• Drug injection for nonmedical reasons
• Sex with a person who injected drugs for nonmedical reasons
• Incarceration for 72 or more consecutive hours
• None of these apply

Primary Care Physician name, phone number, city, and state.

Response

What is your highest level of education?

• Have not attended high school
• Have not graduated high school
• High school graduate
• Some college, no degree
• Associate's degree
• Bachelor's degree
• Master's or other professional degree

Are you currently working for income?

• Full-time employee
• Part-time employee
• Self-employed
• Not currently working

Current living arrangement

• Rent home/apartment
• Own home/apartment
• Temporary housing (dorm, friend's house, hotel)
• Currently homeless
• Deployed in military
• Assisted living facility
• Other

Current household

• Live alone
• Live with spouse or significant other
• Live with parents
• Live with other family
• Live with roommate(s)
• Other

Are you currently covered under medical insurance?

• Yes
• No

Marital status

• Single
• Married
• Divorced
• Widowed
• Partnered

Why are you interested in donation?

Response

Which best describes your current feelings?

• I am still gathering information and have many questions.
• I am ready to start evaluation but not certain donation is right for me yet.
• I am highly motivated to donate and want to start the process soon.

How much do you understand about kidney paired exchange?

• None
• A general idea
• I have already learned about it

Are you open to kidney paired exchange?

• No
• Unsure, I need more information
• Yes, but only if I am not a match with the intended recipient
• Yes, especially if a better match can be found

Emergency contact: first name, last name, phone number, phone type, and relationship.

Response

Best day(s) to contact you

• Monday
• Tuesday
• Wednesday
• Thursday
• Friday

Preferred contact time

• 8:00 AM – 12:00 PM
• 12:00 PM – 5:00 PM

Preferred contact method

• Phone
• Email
• No preference

Any additional information you would like to share with your healthcare providers.

Response