920259 (REV. 12/18)

Nicoletti Kidney Transplant Center 833 Chestnut St, Suite 138 Philadelphia PA 19107 Phone 1-888-855-6649 Fax 215-503-4290

LIVING KIDNEY DONOR SCREENING QUESTIONNAIRE

For office use only: Date received BMI Donor MRN Declined Coordinator Comments:

Donor Name (Last, First) Date SSN Age DOB Gender Height Weight Blood type Marital status Race Caucasian African American Hispanic Asian Pacific OtherAddress: City State Zip Phone number: Home Cell Work Email Best way to contact Time Family/primary care physician’s name

Address: City State Zip Phone number Fax number

Recipient name: Relationship Listed for transplant no yes

Highest education level: None Grade school (1-8) High school or GED Bachelor’s degree Post-graduate degree Employment status: Full time Part time Occupation Are you on disability? Yes No. If yes, please state reason

920259 (REV. 12/18)

SECTION 1: PAST MEDICAL HISTORYHave you ever been treated for high blood pressure? No Yes Have you ever been told that you have heart disease? No YesDo you get frequent chest pains? No YesHave you ever had a heart attack/ bypass surgery/ angioplasty or stent placement? No YesHave you ever had a stress test within the last year? No YesHave you ever had a stroke? No YesIf answered yes to any of the above questions, please provide details Have you ever been treated for diabetes or high blood sugar including gestational diabetes during pregnancy? No YesIf yes, how many years ago were you first treated? Did you use diet pills insulin

SECTION 2: OTHER MEDICAL PROBLEMSCancer No YesLung No YesTuberculosis No YesAsthma No YesGastric/ intestinal issues No YesKidney Stone No YesPancreatitis No YesHepatitis No YesUrinary infection/cancer No YesBladder or kidney stones No YesSexually transmitted diseases No YesProtein in urine No YesNeurological disease No YesLupus No YesArthritis No YesHeadaches/ Migraines No Yes

Melanoma No YesCOPD/Emphysema No Yes

Pneumonia No YesHIV No Yes

Acid reflux/ ulcers No YesGallbladder stone/ disease No Yes

Liver disease No YesBleeding or clotting problems No Yes

Bladder infection/cancer No YesProstate Problems No Yes

Kidney disease No YesBlood in urine No Yes

Seizure No YesParalysis/ Stroke No Yes

Neuropathy No Yes

Obstetrics or gynecological problems (cancer/ fibroid/ endometriosis/ polycystic ovaries) No YesPregnancies/ miscarriages/ abortions No Yes

If answer to any of the above questions is yes, please provide details

SECTION 3: SURGICAL HISTORYList the surgical operations you have had in the past Date

920259 (REV. 12/18)

SECTION 4: MEDICATION LIST

SECTION 5: MEDICATION OR FOOD ALLERGIES List the medications or foods you are allergic to and the reaction you had when you took them:

SECTION 6: FAMILY HISTORYWhich of these diseases are found among any of your parents, brothers, sisters, extended family or children? diabetes high blood pressure kidney cancer cancer kidney disease coronary artery disease dialysis dependent transplant others

SECTION 7: PSYCHO-SOCIAL INFORMATIONHow often do you speak or see the recipient? Please tell us what motivated you to want to be considered as a living donor? Cigarette smoking never quit smoking at age # packs per day

started smoking at age still smoking # packs per day Alcohol never drink socially past heavy drinker present heavy drinker

Details Intravenous drug use never quit within past year quit over a year ago still using

Details Other illicit/ recreational drug use never quit within past year quit over a yr ago still using

Details Have you ever been treated for substance use? No Yes

If yes, when and where? Have you ever been diagnosed with depression, anxiety, schizophrenia, bipolar disorder, personality disorders? No Yes

If yes, please provide details Have you ever taken medications and/or received therapy because of depression, anxiety or other mental illness or emotional problems? No Yes

If yes, please provide details, including provider of treatment

Have you ever had thoughts about hurting yourself or attempted suicide? No Yes If yes, please provide details