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Living Kidney Donor Questionnaire

Potential Living Kidney Donor Questionnaire

There is no greater gift than the gift of life. Donating a life-giving kidney is the most remarkable gift you can give another person. Without a healthy living donor, patients can wait years before a kidney becomes available. Through extraordinary generosity, donors are able to make an immediate impact on another person's life. If you are interested in donating your kidney, please complete and submit our living donor intake form.

* = Required

Please note: This form resets after 5 minutes of no activity. If you have not received a phone call from us within 2-3 business days, please call 603-653-3931 to confirm that the form has been received.

Donor Information

First Name:

Full Middle Name:

Last Name:

Date of Birth:

You must be 21 years or older. Enter as MM/DD/YYYY

Gender:

Male Female Non-Binary/Third Gender Prefer to Self-Describe

Donor Contact Information:

Primary Phone:

###-###-####

Secondary Phone:

###-###-####

Email:

Best time to contact:

Mailing Address:

City/Town:

State:

Zip Code:

Recipient Information

Recipient Name:

Please include first and last name.

What is your relation to recipient?:

Blood Relative Non-Blood Relative Friend Other

What is your blood type? Select:

A B O AB Unknown/Not Sure

How did you hear about their need?:

Are you interested in National Living Donor Assistance Center (NLDAC) for lost wage reimbursement, travel expenses, and dependent care costs?

Yes No

Donor General Health Information

Height (in inches):

Current Weight (in pounds):

PCP Name:

PCP Institution:

Date of Most Recent Physical Exam:

Do any of the following apply to you?

Are you a current or former smoker?

Yes-Current Yes-Former No-Never Smoked Unknown/Not Sure

How frequently do you drink alcohol?

Every Day Every Week A Few Times per Month A Few Times per Year Never Unknown/Not Sure

Do you ever use any recreational drugs?

Yes No Unknown/Not Sure

Cannabis, cocaine, etc.

Do you have an active infection?

Yes No Unknown/Not Sure

Do you have a history of an infectious disease (HIV, Hepatitis B or C)?

Yes No Unknown/Not Sure

Do you have a history of kidney stone(s)?

Yes No Unknown/Not Sure

Do you have high blood pressure?

Yes No Unknown/Not Sure

Do you have diabetes?

Yes No Unknown/Not Sure

Do you have a history of cancer?

Yes No Unknown/Not Sure

Do you have a mental health diagnosis?

Yes No Unknown/Not Sure

Other Health History

Please list your current medical problems:

Please list any surgeries you have had:

Please list any medications you are currently taking:

Please list any allergies you have:

This page will refresh with submission confirmation. If page does not refresh, please make sure you have completed all required items. Thank you.

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