myDH -

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 48 hours, 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:

Donor Contact Information:

Primary Phone:

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

Secondary Phone:

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

Email:

Mailing Address:

City/Town:

State:

Zip Code:

Recipient Information

Recipient Name:

Please include first and last name.

What is your relation to recipient?:

What is your blood type? Select:

How did you hear about their need?:

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?

How frequently do you drink alcohol?

Do you ever use any recreational drugs?

Cannabis, cocaine, etc.

Do you have an active infection?

Human Immunodeficiency Virus (HIV) Diagnosis?

Have you had any kidney stones in the last 10 years?

Do you have diabetes?

Do you have a current cancer?

Mental Health Diagnosis?

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:

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