Appointment Request Form | Allina Health Living Kidney Donor

Living Kidney Donor Form

Ensuring the privacy and security of your data is a top priority for us. You can rest easy, knowing that we take every precaution to secure the information that you submit in the living kidney donor form.

* First name

* Last name

* Middle initial

* How would you like us to address you?

* Date of Birth

* Social Security (required by UNOS to be registered as a donor)

* Address

* County

* City and State

* Zip code

* Gender on birth certificate

* Ethnicity

* Marital Status

* Employment status

* Employer

* Occupation

* Do you have health insurance?

* Do you have life insurance?

Contact information

* Cell phone

* May we leave a message?

* Email address

* Other phone

Emergency contact information

* Emergency contact name

* Relationship to you

* Phone number

Recipient information

* Your intended recipient’s name

* Relationship to recipient

* What is motivating you to look into donation?

Medical history

* Height

* Weight

* Have you ever had or do you have any significant illnesses?

* Please provide additional details in comments:

* Have you ever been hospitalized?

* Please provide additional details in comments:

* Have you ever had surgery?

* Please provide additional details in comments:

* Have you ever been diagnosed with kidney disease?

* Please provide additional details in comments:

* Have you ever had kidney stones?

* Please provide additional details in comments:

* Have you ever been told you have proteinuria (protein in your urine)?

* Please provide additional details in comments:

* Have you ever been told you have hematuria (blood in urine)?

* Please provide additional details in comments:

* Have you ever had a UTI (urinary tract infection)?

* Please provide additional details in comments:

* Do you have diabetes or pre-diabetes?

* Please provide additional details in comments:

* Do you have high blood pressure?

* If you have high blood pressure, what medications do you take?

* If you have high blood pressure, how old were you when it was diagnosed?

* Are you pregnant or planning on becoming pregnant?

* Please provide additional details in comments:

* Do you take hormones for birth control?

* Please provide additional details in comments:

* Have you had any miscarriages?

* Please provide additional details in comments:

* Have you ever had a heart attack?

* Please provide additional details in comments:

* Do you experience chest pain at rest or with activity?

* Please provide additional details in comments:

* Have you ever had a stroke?

* Please provide additional details in comments:

* Do you have high cholesterol or triglycerides?

* Please provide additional details in comments:

* Do you have or have a history of an infectious disease (Hepatitis, HIV, etc.)?

* Please provide additional details in comments:

* Have you ever had cancer?

* Please provide additional details in comments:

* Do you have any liver issues?

* Please provide additional details in comments:

* Do you have any bleeding problems?

* Please provide additional details in comments:

* Have you ever had blot clots?

* Please provide additional details in comments:

* Do you have any neurological issues? Please provide additional details in comments:

* Do you have an auto-immune disorder? Please provide additional details in comments:

* Do you have any psychiatric illness? Please provide additional details in comments:

* Do you take any medications (includes prescription, OTC, supplements, or traditional remedies)? Please provide additional details in comments:

* Do you often take non-steroidal anti-inflammatory medications such as ibuprofen, naproxen, aspirin, indomethacin? Please provide additional details in comments:

* Do you have any allergies to medications?

* Do you have a primary care provider?

* If yes, name, clinic phone number and location where you are seen:

* Do you have any other providers (OB/GYN, urology, cardiology, etc.)?

* When was your last routine annual exam?

* Are you up-to-date on your mammogram? Please provide additional details in comments:

* Are you up-to-date on your Pap/pelvic? Please provide additional details in comments:

* Are you up-to-date on your colonoscopy? Please provide additional details in comments:

* Are you up-to-date with PSA? Please provide additional details in comments:

* Any additional comments regarding your medical history?

Social history

* Do you use alcohol?

* Do you have a history of or current alcohol abuse?

* Please provide additional details in comments about alcohol use:

* Do you use any non-prescription drugs?

* Do you currently use, or have you historically used, any illicit substances? Please provide additional details in comments:

* Do you have any chemical dependency (current or historical)?

* Please provide additional details in comments about chemical dependency use:

* Do you currently smoke?

* Are you a former smoker?

* If former smoker, how long did you smoke, how much did you smoke, and when did you quit?

* Do you currently vape?

* Do you have a history of vaping?

* Do you currently chew tobacco?

* Do you have a history of chewing tobacco use?

* Please provide additional details in comments about vaping or tobacco use:

Family history

* Any family members with kidney disease or kidney problems?

* Please list family members:

* Any family members with diabetes?

* Please list family members:

* Any family members with high blood pressure (hypertension)?

* Please list family members:

* Any family members with heart disease?

* Please list family members:

* Any family members with bleeding or clotting disorder?

* Please list family members:

* Any family member with cancer?

* Please list family members: