- Reference Number: HEY-916/2017
- Departments:
- Last Updated: 20 July 2017
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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 hyp-tr.live.donation@nhs.net
Full Name: |
NHS Number: | Date of birth: | Blood group: |
Sex: Male/female:
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Height:
Weight: |
BMI
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Address:
Postcode: |
Email Address:
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Occupation: | Any dependants? |
Telephone number (home):
Telephone number (work): |
Mobile:
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Family doctor/GP:
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GP’s telephone number:
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Name of the recipient to whom you wish to direct your donation:
Date of birth: |
ABO (for office use only)
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What is your relationship to the recipient?
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Anonymous donation: Yes / No
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General Health: | |||||||||||||||
Have you any current health problems? If you, please give details:
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Have you been admitted to hospital or hand an operation? If yes, when and why?
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Do you routinely take any medications (including over the counter medications)? If yes, please list:
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Do you have a close family member with diabetes? If so, what relation are they to you? | |||||||||||||||
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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 |
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