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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