Patient Onboarding Questionnaire
Patient's Full Name
*
Patient's Email Address
*
example@example.com
Patient's Date of Birth
*
-
Month
-
Day
Year
Occupation
*
Agriculture, food and natural resources
Architecture and construction
Arts, A/V technology and communications
Business management and asministration
Education and training
Finance
Government and public administration
Health science
Hospitality and tourism
Human services
Information technology
Law, public safety, corrections and security
Manufacturing
Marketing
Science, technology, engineering and mathematics
Transportation, distribution and logistics
Other
Time on transplant wait list?
*
Less than 1 year
1 - 2 years
3 - 4 years
More than 4 years
Are you currently on dialysis
*
Yes
No
How long have you been on dialysis?
Less than 1 year
1 - 2 years
3 - 4 years
More than 4 years
On a scale of 1 to 10, how familiar are you with living donation?
*
Not familiar at all
1
2
3
4
5
6
7
8
9
Extremely familiar
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?
*
Not familiar at all
1
2
3
4
5
6
7
8
9
Extremely familiar
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?
*
Yes
No
What communities, groups, causes, or organizations are you an active member of?
Religious
Professional
Athletic/Health
Local Group/Organization
Military/VA
Hobbies
Other
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 hour
1 to 3 hours
4 to 6 hours
On a scale of 1 to 10, how comfortable are you with sharing your need for a living kidney donor?
*
Not comfortable at all
1
2
3
4
5
6
7
8
9
Extremely comfortable
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?
*
Not comfortable at all
1
2
3
4
5
6
7
8
9
Extremely comfortable
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)?
*
Yes
No
How much time do you spend on social media each week?
*
Less than 1 hour
1 to 3 hours
4 to 6 hours
More 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?
*
Yes
No
Do you have 1 to 3 people who are willing to support your search for a living kidney donor who use social media?
*
Yes
No
Submit
Should be Empty: