GiftWorks Patient Onboarding Questionnaire

Patient Onboarding Questionnaire
Patient's Full Name*
Patient's Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Date of Birth*

MonthDayYear
Gender*

FemaleMale
Marital Status*

MarriedSingle
Do have children?

YesNo
Employment Status*

EmployedNot EmployedRetired
Occupation*

Agriculture, food and natural resourcesArchitecture and constructionArts, A/V technology and communicationsBusiness management and asministrationEducation and trainingFinanceGovernment and public administrationHealth scienceHospitality and tourismHuman servicesInformation technologyLaw, public safety, corrections and securityManufacturingMarketingScience, technology, engineering and mathematicsTransportation, distribution and logisticsOther
Which languages do you use and at what percent?*
Time on transplant wait list?*

Less than 1 year1 - 2 years3 - 4 yearsMore than 4 years
Are you currently on dialysis*

YesNo
How long have you been on dialysis?

Less than 1 year1 - 2 years3 - 4 yearsMore than 4 years
On a scale of 1 to 10, how familiar are you with living donation?*

1

2

3

4

5

6

7

8

9

10

1 is Not familiar at all, 10 is Extremely familiar
Living Donation Familiarity (Hidden)
On a scale of 1 to 10, how important is it for you to find a living kidney donor?*

1

2

3

4

5

6

7

8

9

10

1 is Not familiar at all, 10 is Extremely familiar
Living Donation Importance (Hidden)
Are you an active member of a community, group, cause, or professional organization?*

YesNo
What communities, groups, causes, or organizations are you an active member of?

ReligiousProfessionalAthletic/HealthLocal Group/OrganizationMilitary/VAHobbiesOther
Communities/Groups/Causes/Orgs (hidden)
Other community, group, cause or organization
How much time are you willing to invest in your search for a living kidney donor each week?*

Less than 1 hour1 to 3 hours4 to 6 hours
On a scale of 1 to 10, how comfortable are you with sharing your need for a living kidney donor?*

1

2

3

4

5

6

7

8

9

10

1 is Not comfortable at all, 10 is Extremely comfortable
Donation Info Sharing Comfort Level (Hidden)
On a scale of 1 to 10, how comfortable are you asking for help when you need it?*

1

2

3

4

5

6

7

8

9

10

1 is Not comfortable at all, 10 is Extremely comfortable
Asking for Help Comfort Level (Hidden)
Are you active on social media (i.e. Facebook, LinkedIn, Instagram, TikTok)?*

YesNo
How much time do you spend on social media each week?*

Less than 1 hour1 to 3 hours4 to 6 hoursMore than 6 hours
Do you have 1 to 3 people willing to support your search for a living kidney donor by sharing your story with those they know?*

YesNo
Do you have 1 to 3 people who are willing to support your search for a living kidney donor who use social media?*

YesNo
Do you have children?*

YesNo
What age are your children?
If you have children, are they willing to help share your story on social media?

YesNo
Have you had people step forward as potential living donors in the past?*

YesNo
I understand that, as part of the GiftWorks’ Program, I will be asked to share my story on my social media platforms and with those I know. I understand that my involvement is critical to the success of this program. I agree to actively engage with the GiftWorks team, follow all provided guidance, and proactively seek opportunities to share my story with my community and network if I am accepted.*

I understand and agree.
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