Living Donor Liver Transplant Program
Living Donor Kidney Transplant Program
Donor Health History
Please submit this completed form, along with a copy of your blood type (if known), to the transplant office (Live Donor Co-ordinator, Level 1, Lincoln Wing, St James’s University Hospital, Leeds LS9 7TF) or email leedsth-tr.livedonorrenaltransplant@.
|Full Name |
|DEMOGRAPHICS |
|NHS NO: |Date of Birth: |Blood Group: |
| | |(If known) |
|Sex: Male / Female |Height: cm |Office use only |
| |Weight: kg |BMI: |
|Address: Email address: |
| |
| |
|Postcode: |
| | |
|Home Telephone: ( ) |Mobile: |
|Family Doctor/GP | |
| |Telephone: ( ) |
|Please indicate the name of the recipient to whom you wish to direct your donation: |Office use only |
|Date of Birth: |ABO |
| |
|What is your relationship to the recipient? □ Anonymous Donation |
| |
|Occupation: Do you have any dependents: |
|GENERAL HEALTH: |
|1. |Have you any current health complaints? | |
| | |□ Yes □ No |
| |Have you ever been admitted to hospital or had any operations? | |
|2. |If yes, when and why? |□ Yes □ No |
| |Do you routinely take any medications (including over the counter)? | |
|3. |If yes, list: |□ Yes □ No |
| |Do you smoke? | |
|4. |Live donors must be non smokers, are you willing to stop? |□ Yes □ No |
| |Do you have any close family members with diabetes? |□ Yes □ No |
|5. |If so who? | |
| |Men/women aged over the age of 60: Have you had bowel screening? | |
|6. | |□ Yes □ No |
| |Females only: Are you up to date with cervical screening? | |
|7. | |□ Yes □ No |
| |
|Cancer |□ Yes □ No | |
|High blood pressure |□ Yes □ No | |
|Diabetes |□ Yes □ No | |
|Kidney stones |□ Yes □ No | |
|Depression |□ Yes □ No | |
|Heart Disease |□ Yes □ No | |
|Blood clot / DVT |□ Yes □ No | |
|Stroke |□ Yes □ No | |
|OTHER |
|Are you willing to consider the National Living Donor Kidney Sharing Scheme (NLDKSS)? | |
| |□ Yes □ No |
|Are you willing for us to review your medical and GP records? | |
| |□ Yes □ No |
| | |
|Are you aware that there is a living donor reimbursement scheme that may cover your loss of earning and |□ Yes □ No |
|travel expenses? |□ I would like further information|
| | |
|Donating your kidney requires 8-12 weeks off work to recover, do you think you are able to take time off |□ Yes □ No |
|work? | |
I have answered these questions to the best of my ability.
|Name of Potential Donor |Signature |Date dd/mm/yyyy |
| | | |
Office Use Only:
|Name of Person Administering Questionnaire |Signature |Date dd/mm/yyyy |
| | | |
| |
|Office use only |
| |
|Date Received: ___________________________ |
| |
|Date Reviewed: ___________________________ |
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