Name
Iowa Methodist Transplant Center
1215 PLEASANT STREET, SUITE 506
DES MOINES, IA 50309
PHONE: 515-241-4044
FAX: 515-241-4100
Kidney Transplant Evaluation Form
Personal Information
Full Name:_________________________________________________________________
□ Male or □ Female
Date of Birth:____________________
Maiden Name or any other name under which records may be kept:__________________________
Mailing Address:___________________________________________________________________
City:____________________ State:______________________ Zip Code:___________________________
How many miles is it from your home to Methodist? ______________________________________
Home Telephone:________________ Cell phone:_________________ Work phone:_____________
Email address:_____________________________________________________________________
Social Security Number:______________________
Race:_____________________________
Place of Birth:_____________________ Are you a US Citizen? □ Yes □ No
Is English your primary language? □ Yes □ No
If not, what is your primary language?_______________________________________
Martial Status: □ Single □ Married □ Divorced □ Widowed
Spouse/Significant Other’s name:___________________________________________
Telephone number:____________________________
Emergency Contacts:
Name:____________________________________ Telephone Number:_______________________
Name:____________________________________ Telephone Number:_______________________
Name:____________________________________ Telephone Number:_______________________
Name:____________________________________ Telephone Number:_______________________
Occupation:____________________________________
Employer:______________________________________
Are you currently working? □ Yes □ No If so, □ Full time or □ Part time?
Occupation_____________________________Employer___________________________________
What is your highest level of Education?________________________________________________
How do you learn best, please check all that apply:
□ Reading
□ Writing
□ Listening
□ Observing
□ Performing
□ Other:______________________________________
Do you have access to a computer with the internet? □ Yes □ No
Email address:_____________________________________________________________________
Kidney Information
Your kidney doctor or dialysis unit can help answer this question and those following if you are unsure of the answers.
Who is your Nephrologist or kidney doctor?________________________________________
Telephone number:______________________________ Fax number:________________________
What is the cause of your kidney failure? ________________________________________________
Have you ever had a kidney biopsy? □ Yes □ No
If so, When?___________________________ Where?____________________________________
Have you ever had a ultrasound of your kidneys? □ Yes □ No
If so, When?___________________________ Where?____________________________________
Are you currently on Dialysis? □ Yes □ No
If so, what type? □ Hemodialysis □ Peritoneal dialysis
If you are on hemodialysis, what type of access do you have? □ Fistula □ Central Line
Where is your dialysis access located on your body?_______________________________________
What is the name of your dialysis center?____________________________
Telephone number: ______________________________ Fax number: _______________________
What days and times do you dialyze? __________________________________________________
Insurance Information
Primary Insurance (if not Medicare):____________________________________________________
Policy holder’s name:_____________________________ Effective Date:__________________ Policy number:___________________________
Telephone number (usually located on the back of your insurance card):___________________
*Please call your primary insurance provider to insure that you are covered for kidney transplant at our center.*
Name of person you spoke to:______________________ Date:_____________ Time:____________
It is not necessary to call your insurance company if you have Medicare/Medicaid as your primary insurance.
Medicaid ID number:____________________________Effective Date:________________________
Medicare ID number:____________________________Effective Date:________________________
Secondary Insurance:_______________________________________________________________
Policy holder’s name:______________________________ Effective Date:_____________________ Policy number:_______________________________
Telephone number (usually located on the back of your insurance card):________________________________
Additional Insurance: Plans:__________________________________________________________
Policy holder’s name:_________________________________ Effective Date:__________________ Policy number:_______________________________
Telephone number (usually located on the back of your insurance card):_______________________
Are you currently listed at any other transplant center? □ Yes □ No
If so, what center/s? ________________________________________________________________
Medication Information
Please list all of your current medications including name, dosage, and frequency. If you are taking herbal medications or supplements, please list these, as well:
For example: Aspirin 81mg Daily
• Medication name: __________________Dose: _________ Frequency: __________________
• Medication name: __________________Dose: _________ Frequency: __________________
• Medication name: __________________Dose: _________ Frequency: __________________
• Medication name: __________________Dose: _________ Frequency: __________________
• Medication name: __________________Dose: _________ Frequency: __________________
• Medication name: __________________Dose: _________ Frequency: __________________
• Medication name: __________________Dose: _________ Frequency: __________________
• Medication name: __________________Dose: _________ Frequency: __________________
• Medication name: __________________Dose: _________ Frequency: __________________
• Medication name: __________________Dose: _________ Frequency: __________________
• Medication name: __________________Dose: _________ Frequency: __________________
Do you have any medication allergies? If so, please list these below:
Do you have any environmental/food allergies? If so, please list these below:
Do you smoke? □ Yes □ No
If so, how much/how often?___________________________________________________________
If you have smoke in the past, how much/how often?_______________________________________
What is the approximate date that you quit smoking?_______________________________________
Do you consume alcoholic beverages? □ Yes □ No
If so, how much/how often?___________________________________________________________
Do you use or have you used illegal drugs? □ Yes □ No
What illegal drugs? Please also list approximate date last use:_______________________________
________________________________________________________________________________
Family History Information
Family Member Age Current Health Status/Cause of Death
Father ________ ___________________________________________
Mother ________ ___________________________________________
Spouse ________ ___________________________________________ □ Brother or □ Sister ________ ___________________________________________
□ Brother or □ Sister ________ ___________________________________________
□ Brother or □ Sister ________ ___________________________________________
□ Brother or □ Sister ________ ___________________________________________ □ Brother or □ Sister ________ ___________________________________________
□ Brother or □ Sister ________ ___________________________________________
□ Brother or □ Sister ________ ___________________________________________ □ Male or □ Female Child ________ ___________________________________________
□ Male or □ Female Child ________ ___________________________________________
□ Male or □ Female Child ________ ___________________________________________ □ Male or □ Female Child ________ ___________________________________________
□ Male or □ Female Child ________ ___________________________________________
Are you or any of your children adopted?
□ Yes, I am adopted. □ Yes, my children are adopted. □ No, neither.
If so, please indicate which of your children are adopted above.
Medical Information
What is the date of your last physical exam?_____________________________________________
Who is your primary care physician or family doctor? _____________________________________
Telephone Number:________________________ Fax Number:______________________________
What is your current height________ and weight________?
Are you Diabetic? □ Yes □ No
If so, At what age were you diagnosed as a diabetic?_____________________________________
Do you take insulin injections to control your blood sugars? □ Yes □ No
If so, at what age did you begin taking insulin injections? _________________________________
Do you take pills for your blood sugar? □ Yes □ No
How often do you check your blood sugar? ______________________________________________
Which one of your doctors manages your diabetes?_______________________________________
Telephone Number:___________________________ Fax Number:___________________________
Do you have hypertension or high blood pressure? □ Yes □ No
If so, at what age were you diagnosed with high blood pressure?______________________
Do you have hyperlipidemia or high cholesterol? □ Yes □ No
Have you are had a stroke or transischemic attack/TIA? □ Yes □ No
If so, when? ___________________________________________
What side effects, if any, do you have from your stroke/TIA such as paralysis, weakness, or numbness in parts of your body? ______________________________________________________
Do you have lung disease such as COPD, emphysema, chronic shortness of breath or asthma?__________________________________________________________________________
Do you wear oxygen at home or use inhalers?_____________________________________________
Have you ever had a chest x-ray? □ Yes □ No
If so, when? ___________________________ where? ____________________________________
Do you have a pulmonologist or lung doctor? □ Yes □ No
If so, who?_____________________________________________
Telephone Number:________________________Fax Number:______________________________
Have you ever been diagnosed with tuberculosis? □ Yes □ No
Have you had a tuberculosis or TB skin test? □ Yes □ No
If so, when? _______________________________ where? ________________________________
Have you ever had the chicken pox or shingles? □ Yes □ No
Have you ever been diagnosed with a sexually transmitted disease such as gonorrhea, syphilis, herpes, chlamydia or genital warts? □ Yes □ No
If so, which one/s?__________________________________________________________________
Have you been diagnosed with heart disease? □ Yes □ No
Have you ever had a heart attack? □ Yes □ No
Have you ever had an Echocardiogram? □ Yes □ No
If so, when? ___________________________ where? ____________________________________
Have you ever had a cardiac stress test? □ Yes □ No
If so, when? ____________________________ where? ___________________________________
Have you ever had a cardiac angiogram or cardiac catheterization? □Yes □ No
If so, when? _____________________________ where? __________________________________
Have you ever had stents placed in your heart? □ Yes □ No
If so, when? ___________________________where? ____________________________________
Have you ever had a heart surgery? □ Yes □ No?
If so, when? _____________________________where? ___________________________________
Have you had a pacemaker placed to control your heart rate? □ Yes □ No
If so, when? _____________________________where? ___________________________________
Have you been with peripheral vascular disease or PVD? □ Yes □ No
Have you have stents placed anywhere in your body other than your heart such as your legs or kidneys? □ Yes □ No
If so, when? _____________________________where? ___________________________________
Who is you Cardiologist or heart doctor?________________________________________________
Telephone Number:________________________ Fax Number:______________________________
Do you have problems with your Gallbladder or has it been removed? □ Yes □ No
□ Removed: When? ________________________________________________________________
Do you have stomach ulcers? □Yes □ No
Do you have chronic pain? □ Yes □ No
If so, where on your body?_______________________________
What helps to relieve your pain?______________________________________________________
Do you see a pain specialist? □ Yes □ No
If so, who is your pain specialist?______________________________________________________
Telephone Number:__________________________ Fax Number:____________________________
Do you have or have you ever had depression, anxiety, or any other mental health concerns?
□ Yes □ No
If so, how was/is this treated?_________________________________________________________
Have you ever been seen by a psychiatrist or mental health counselor? □ Yes □ No
If so, who?________________________________________________________________________
How well do you go about your daily activities?___________________________________________
________________________________________________________________________________
What do you do for exercise?_________________________________________________________
What hobbies do you have? __________________________________________________________
________________________________________________________________________________
Do you have any dental issues such as decay, gum disease, or sores in your mouth? □ Yes □No
If so, please list any dental problems you have.__________________________________________
When is the last time you visited the dentist? ____________________________________________
Who is your dentist?________________________________________________________________
Telephone Number:_________________________Fax Number:____________________________
Do you have hearing or vision difficulties such as deafness or blindness? □ Yes □ No
Have you ever had a colonoscopy? □ Yes □ No
If so, when? ____________________________where? ____________________________________
Have you ever been diagnosed with cancer? □ Yes □ No
What type?___________________________________________
When were you diagnosed?____________________________
Did you have to have a surgery for this? □ Yes □ No
Did you undergo chemotherapy or radiation for this? □ Chemotherapy □ Radiation
□ Other Treatment:________________________________________________________________
Have you ever been diagnosed with a blood disorder? □ Yes □ No
If so, what disorder?________________________________________________________________
When? ___________________________By whom?______________________________________
Have you ever had bladder or kidney infections? □ Yes □ No
Have you ever had kidney stones? □ Yes □ No
Do you have trouble emptying your bladder? □ Yes □ No
How much urine do you make per day?
□ None □ One cup to one quart □ More than one quart
What is your blood type?_____________________
Have you ever had a blood transfusion? □ Yes □ No
If so, when?______________________________________
Approximately how many units of blood did you receive?__________________________________
What is the approximate date that you last received a blood transfusion? __________________
Are you willing to accept blood transfusions? □ Yes □ No
Have you ever been diagnosed with hepatitis, cirrhosis, or liver disease? □ Yes □ No
If so, what disease?______________________________ By whom?__________________________
Have you ever had a transplant of any type? □ Yes □ No
Have you ever had a kidney transplant? □ Yes □ No
If so, when did you receive your kidney transplant?_______________________________________
Was your kidney transplant from a living or deceased donor?______________________________
If your donor was living, who donated to you? Please also noted your relation to you donor?___________________________________________________________________________
Why did your kidney transplant stop working?____________________________________________
When did you kidney transplant stop working? ___________________________________________
What anti-rejection or immunosuppression/anti-rejection medication were/are you on? If you are no longer on transplant medications, please indicate when you stop taking these. ________________________________________________________________________________
________________________________________________________________________________
What operations or surgeries have you had? Please list all operations that you have had.
• Operation__________________________ Approximate Date________________________
• Operation__________________________ Approximate Date________________________
• Operation__________________________ Approximate Date________________________
• Operation__________________________ Approximate Date________________________
• Operation__________________________ Approximate Date________________________
• Operation__________________________ Approximate Date________________________
• Operation__________________________ Approximate Date________________________
• Operation__________________________ Approximate Date________________________
Have you ever been hospitalized? □ Yes □ No
• Hospital/Reason for hospitalization_________________________________________________________
Approximate Date of hospitalization____________________________________
• Hospital/Reason for hospitalization_________________________________________________________
Approximate Date of hospitalization____________________________________
• Hospital/Reason for hospitalization_________________________________________________________
Approximate Date of hospitalization____________________________________
• Hospital/Reason for hospitalization_________________________________________________________
Approximate Date of hospitalization____________________________________
• Hospital/Reason for hospitalization_________________________________________________________
Approximate Date of hospitalization____________________________________
Please provide a list of all of your healthcare providers:
• Doctor____________________________________Speciality__________________________
Telephone:_____________________________ Fax:________________________________
• Doctor____________________________________Speciality__________________________
Telephone:_____________________________ Fax:________________________________
• Doctor____________________________________Speciality__________________________
Telephone:_____________________________ Fax:________________________________
• Doctor____________________________________Speciality__________________________
Telephone:_____________________________ Fax:________________________________
• Doctor____________________________________Speciality__________________________
Telephone:_____________________________ Fax:________________________________
• Doctor____________________________________Speciality__________________________
Telephone:_____________________________ Fax:________________________________
• Doctor____________________________________Speciality__________________________
Telephone:_____________________________ Fax:________________________________
Any additional information that you feel it is important for us to know about your medical history or current situation?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- company name and stock symbol
- why your name is important
- native american name generator
- why is my name important
- why is god s name important
- last name that means hope
- name for significant other
- name synonym list
- me and name or name and i
- name and i vs name and me
- name and i or name and myself
- name and i or name and me