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?

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________

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