Living Donor Intake Form

Our Kidney Program

Thank you for contacting the Kidney Program at MedStar Georgetown Transplant Institute! If you do not have an email address or would like to complete this information over the phone, please contact our team at 202-444-3701. If you are a physician, dialysis unit, or a patient looking for more information about transplantation, please fill out only the required fields, marked with a red asterisks.

If you are ready to schedule a transplant evaluation appointment, please fill out the entire form.
Use the Next button at the bottom of the page to continue. Note that the information will not be saved or reviewed until you click Submit on the final page. All information disclosed in this questionnaire is confidential.

A member of the transplant team will contact you shortly.

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Donor Information

First Name

Middle Name

Last Name

Date of Birth

Gender

US Citizenship

Race

Employment Status

Education

SSN

Height ft in

Weight

Patient Contact Information

Street Address

City

State

Postal Code

Telephone

Section 1: Your Demographic Information

Mothers Race

Mother Other Race

Fathers Race

Father Other Race

Would you like an interpreter?

Primary Language (if other than English)

Present Relationship Status

Emergency Contact Name

Emergency Contact's Sex

Emergency Contact's Phone Number

Emergency Contact Relationship

Do you give MGTI your permission to email you your health information?

Do you give MGTI your permission to leave your health information in a voicemail to your preferred phone?

Do you have a temporary US address?

My preferred contact route is

Physician's Name

Physician's Office Phone

The MedStar Georgetown Transplant Institute has several clinic locations. Where would you prefer to be seen?

Section 2: Your Intended Recipient

Do you have an intended recipient?

Recipient First Name

Recipient Middle Name or Initial

Recipient Last Name

Recipients Date of Birth

Recipients Gender

I am the Recipient's

Specify Relationship if Other

Specify Website if that is how you met

Section 3: Your Medical History

Please tell us if you have had any of the following:

High Blood Pressure/Hypertension

Heart Attack

Chest Pain with Exercise

Stroke or TIA

If you have had a cardiac stress test in the past, what were the results?

Diabetes

Gestational Diabetes

How is your Diabetes controlled?

Miscarriage

Please Specify How Many

Addiction

Please Specify Type

If Other, Please Specify

Date of Last Use

Cancer

Specify When

Specify Cancer Type and Location

Specify Cancer Treatment

Mental Health Issues

Liver Problems

Hepatitis

HIV

Kidney Disease

Please Specify Type of Kidney Disease

Please Provide Disease Details

Kidney Stones

Specify When and How Many

Seizures

Suicide Attempts

Abnormal PAP results

If Yes, Please Specify

Abnormal Mammogram

If Yes Please Specify

Abnormal PSA

If Yes, Please Specify

Abnormal Colonoscopy

If Yes, Please Specify

Section 4: Your Surgical History

List any surgical operations you have had in the past:

Have you ever had surgery or a major illness in the past?

First Surgery or Illness

Second Surgery or Illness

Third Surgery or Illness

Fourth Surgery or Illness

Fifth Surgery or Illness

More Surgeries or Illnesses

Section 5: Your Current Medication List

List the medications you are taking now, including prescriptions, over-the-counter, herbs, or supplements:

Do you currently take any prescriptions

First Medication

Second Medication

Third Medication

Fourth Medication

Fifth Medication

More Medications

Section 6: Allergies

List the medications or foods you are allergic to and the reaction you had when you took them:

Do you have any known allergies to medication or food?

Are you allergic to Latex?

Please specify your reaction

Are you allergic to Shellfish?

Please Specify Reaction

Are you allergic to X-ray or contrast dye?

Please Specify Reaction

First Allergy and Reaction

Second Allergy and Reaction

Third Allergy and Reaction

Fourth Allergy and Reaction

Fifth Allergy and Reaction

More Allergies

Section 7: Your Family History

Does anyone in your family have any of the following:

Diabetes

Please specify your relationship with the family member

Kidney Disease

Please specify your relationship with the family member

Please Specify Type of Kidney Disease

Please Provide Kidney Disease Details

High Blood Pressure/Hypertension

Please specify your relationship with the family member

Cancer

Please specify your relationship with the family member

Section 8: Your Psycho-social Information

Please complete the following psycho-social information:

How often do you currently speak with or see the recipient?

Please tell us what motivated you to want to be considered as a living donor

What personal values led you to register today?

Employer

What is your present (or past) occupation?

If you are currently employed, will you receive paid leave/ income during your time off for the surgery and recovery periods?

Do you currently have health insurance?

Who will take care of you at home after the surgery?

Have you previously donated blood (if so, how many times?)

Have you previously donated bone marrow or stem cells?

Have you ever travelled or lived outside of the US?

If so, where and for how long?

Do you or have you ever smoked cigarettes?

How many packs per day and for how long?

How long ago did you quit?

Do you or have you ever used other tobacco products?

What type of tobacco?

How many and how often

Date of last use

Do you or have you ever drank alcohol?

How many and how often

Date of last use

Do you or have you ever used intravenous drugs?

Type of Drug

How much and how often?

Date of last use

Do you or have you ever used any other illegal drugs?

Type of Drug

How much and how often

Date of last use

Have you ever been treated for substance abuse?

When and where were you treated?

Have you ever been involved in legal issues involving law enforcement? (including DUI/DWI)

Have you ever been incarcerated?

When and where?

What is your Religion

Will you accept blood products?

Have you ever taken medications to treat depression, anxiety, or other mental illness or emotional problems?

Please list the name of the medication, date of last use, and diagnosis

Have you had a PPD test (Tuberculosis Skin Test) in the last 90 days?

If so, when?

How did you hear about the MedStar Georgetown Transplant Insitiute?

Please specify how you heard

Section 9: Systems Review

Which of these have significantly bothered you lately?

Any metal in your body

Specify Where

Any piercings

Specify Where

Tooth or gum problems

Chest pain

Fluttering in chest

Fainting spells

Shortness of breath

Wheezing

Bloody urine

Cloudy urine

Sores/ discharge from genitals

Abnormal menstrual bleeding

Breast tenderness

Nipple discharge

Anxiety

Depression

Hallucinations

Claustrophobia

Low Thyroid

Consents

If you were determined not to be a match for your intended recipient, would you consider a non-directed donation to a recipient selected by GUMC?

If I am incompatible with my recipient (NOT a match), I am willing to participate in exchange.

Even if I am compatible with my recipient, I am willing to consider a paired kidney exchange