Living Donor Kidney Health History

  • Reference Number: HEY-916/2017
  • Departments:

Please submit this completed form, along with a copy of your blood group (if known), to the Renal Living Donor Nurse, Ward 50, Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ or via email to livedonation@hey.nhs.uk

Full Name:
NHS Number: Date of birth: Blood group:
Sex: Male/female:

 

Height:

Weight:

BMI

 

Address:

 

Postcode:

Email Address:

 

 

Occupation: Any dependants?
Telephone number (home):

Telephone number (work):

Mobile:

 

Family doctor/GP:

 

GP’s telephone number:

 

Name of the recipient to whom you wish to direct your donation:

 

Date of birth:

ABO (for office use only)

 

 

 

What is your relationship to the recipient?

 

Anonymous donation:  Yes / No

 

General Health:
Have you any current health problems?  If you, please give details:

 

Have you been admitted to hospital or hand an operation? If yes, when and why?

 

Do you routinely take any medications (including over the counter medications)? If yes, please list:

 

 

Do you have a close family member with diabetes? If so, what relation are they to you?
Do you smoke? Yes No
Live donors must be non-smokers.  Are you willing to stop? Yes No
Men/women over the age of 60: Have you had bowel screening? Yes No
Females only: are you to date with mammogram? (Age 50-70) Yes No
Females only: Are you up to date with cervical screening? Yes No

 

Have you been diagnosed with any of the following? Type/treatment
Cancer Yes               No
High blood pressure Yes               No
Diabetes Yes               No
Kidney stones Yes               No
Depression Yes               No
Heart disease Yes               No
DVT/Blood clot Yes               No
Stroke Yes               No
Are you willing to consider the national Living Donor Kidney Sharing Scheme Yes No
Are you aware that there is a living donor reimbursement scheme that may cover your loss of earnings and travel expenses?

Would you like further information about this?

Yes

 

Yes

No

 

No

Do you give permission for us to contact your GP for medical records Yes No
Have you watched the kidney transplantation information DVD? Yes No
Donating your kidney requires 8-10 weeks off work to recover.  Do you think you will be able to take this time off work? Yes No
Any other information:

 

I have answered these questions to the best of my ability

Signature:                                                                              Date:

Office use only: Date Received: Date Reviewed: