CCHMC Living Donor Interest Form
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Biological Sex (sex assigned at birth)
*
Male
Female
Indeterminate
Marital Status
*
Please Select
Married
Divorced
Single
Email
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ethnicity/Race (check all that apply)
*
White
Hispanic or Latino
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Cell Phone Number (SMS Confirmation Required)
*
Height/Weight
*
Who is your PCP?
Primary care physician
Who is your OBGYN?
Which Organ are you considering donating?
*
Kidney
Liver
Either Kidney or Liver
Do you have a specific recipient you would like to donate to?
*
Yes
No
Name and info of the specific recipient
*
full name, date of birth, etc.
Motivation to Donate
Why are you interested in becoming a living donor?
Any Allergies?
List all allergies, leave blank if you do not have any allergies
Are you currently on any medications?
*
Yes
No
List all medications, doses, and frequencies
*
Medication, Dose, Frequency
Have you had any surgeries?
*
Yes
No
List all surgeries and dates
*
Surgery, When
Have you ever been diagnosed with kidney disease?
*
Yes
No
Please explain your kidney disease diagnosis
*
Have you had more than 2 occurrences of Kidney Stones?
*
Yes
No
Please explain your experience with kidney stones
*
Have you had 2 or more UTI’s (urinary tract infection) in the last 6 months or 3 in the last 12 months?
*
Yes
No
Please explain your experience with UTI's
*
Have you ever had blood in your urine?
*
Yes
No
Please explain your experience with blood in your urine
*
Have you ever been diagnosed with HIV?
*
Yes
No
Please explain your HIV diagnosis
*
Have you ever been diagnosed with Cancer?
*
Yes
No
History of which cancers? (mark all that apply)
*
Bladder
Bone
Brain
Kidney
Liver
Lung
Non-Hodgkin Lymphoma
Pancreatic
Melanoma
Other
Has cancer been in remission for 5 years or more?
*
Yes
No
Have you ever been diagnosed with Hep C?
*
Yes
No
Please explain your Hep C diagnosis
*
Do you have any autoimmune diseases?
*
Yes
No
Please explain your experience with autoimmune diseases
*
Have you ever been diagnosed with liver disease?
*
Yes
No
Please explain your liver disease diagnosis
*
Have you ever had a stroke?
*
Yes
No
Please explain your stroke experiences
*
Have you ever had Hypertension (high blood pressure)?
*
Yes
No
Please explain your experiences with hypertension/high blood pressure
*
Have you ever had a heart attack or coronary stent?
*
Yes
No
Please explain your experiences with heart attacks or coronary stents
*
Have you ever been diagnosed with diabetes (high blood glucose)?
*
Yes
No
Please explain your experiences with diabetes
*
Are you willing to accept blood transfusions?
*
Yes
No
Are you pregnant or breastfeeding or gave birth in the last 12 months?
*
Yes
No
Please explain your recent experiences with pregnancy, breastfeeding, or giving birth
*
Have you had a miscarriage?
*
Yes
No
Please explain your miscarriage experiences
*
Have you ever been diagnosed with a mental health disorder?
*
Yes
No
Please explain and list your mental health disorder diagnoses
*
Have you had suicidal thoughts or attempts in the last year?
*
Yes
No
Please elaborate on your recent experiences with suicidal thoughts or attempts
*
please explain to the extent you are comfortable
How many alcoholic beverages do you drink in a week?
*
Do you smoke tobacco?
*
Yes
No
Please explain your experiences with smoking tobacco
*
Are you currently taking prescription medication to manage a substance use disorder? (e.g. suboxone or methadone).
*
Yes
No
Please explain your experiences with medical management substance use disorders
*
Do you use any recreational drugs, legal or illegal?
*
Yes
No
Please explain your experiences with recreational drugs
*
Does anyone in your family have the following? (check all that apply)
Hypertension
Heart Disease
Diabetes
Liver Disease
Kidney Disease
Cancer
Please explain each of the family members affected by each of the diagnoses you selected
*
Is your Mother Alive?
*
Yes
No
How old is your mother?
*
years old
What was your mother's cause of death?
*
primary or list multiple
Is your Father Alive?
*
Yes
No
How old is your father?
*
years old
What was your father's cause of death?
*
primary or list multiple
How many siblings do you have?
*
How many children less than 18?
*
How many children older than 18?
*
Signature
Continue
Continue
Should be Empty: