www.ucdmc.ucdavis.edu

Living Donor

Living Kidney Donation Interest Form



Welcome to the UC Davis Living Donor Program. Considering live kidney donation is a tremendous act of kindness. The donation process can be time consuming and we value your time. The first step is to learn whether you have any past or present medical problems that would rule you out as a donor. The following series of questions will allow us to determine whether you might be a suitable donor. Please answer the questions accurately and completely. Only our medical team will use this information and it will not be shared with anyone. Once you complete the questions you will receive a message that will instruct you on the next steps. Again we value your generosity and we thank you for your time.
12/10/2018
Fields marked * are required.
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*Do you take any prescribed medications every day including psychiatric medications? (Do not include vitamins)
If Yes please list your medications.
If you take medication for high blood pressure how long have you been taking it?
*Are you currently under the care of a doctor for any medical or psychiatric conditions?
If yes list the conditions followed by your doctor(s).
*Do you have diabetes?
*Do you currently smoke or chew tobacco?
*Have you ever had a blood clot in your legs or lungs?
*Have you ever had cancer including skin cancer?
If yes what type?
*Have you ever been diagnosed with hepatitis C?
*Have you ever had a stroke?
*Have you ever been admitted to the hospital for more than one night? (Please do not include childbirth)
Please list your hospital admissions
*Are you allergic to iodine?
*Do you take protein supplements?
*Do you have sleep apnea or ever prescribed a CPAP machine?
What is your blood type?
*Which country were you born in?
*Have you traveled to or lived in Mexico/ Central America/ or South America more than a short vacation as a tourist?
*Have you been to rural areas in Mexico / Central America/ or South America?

This questionnaire is confidential and the information collected is protected by Federal Law.


Living Donor Form Errors