Living Donor and Potential Living Donor Initial Registration Worksheet
(Kidney and Liver)
1. Donor Center:
2. Living Donor Collective (LDC) ID Number: ____________
3. UNOS Donor ID Number (if/when assigned): ____________
4. Donor Candidate Name: ___________________________
5. Address: ________________________________________
___________________________________________
City: ____________________
State: ____________________
Zip Code: ________________________
6. Mailing Address: ___________________
____________________________
City: ____________________
State: ____________________
Zip Code: ________________________
7. Primary Phone: ________________________
8. Secondary Phone: ______________________________
9. Primary Email: ________________________________
10. Secondary Email: ________________________________
11. SSN#: ____________________
11a. 9FN if no SSN: _______________________________
12. Date of Birth: _____________________________________
13. Whom can we contact if we cannot reach the donor candidate? (Only to obtain donor contact information; no other information will be shared)
Name: _____________________________
Address: ___________________________
City: _______________________________
State: _______________________________
Phone 1:___________________________
Phone 2:___________________________
Email: _____________________________
Relationship to donor candidate: ____________________
13a. Preferred method of contact:
Primary phone
Text
Voice
Secondary phone
Primary email
Secondary email
Postal Mail
Other, Specify:
Social Media: Specify (Facebook, Twitter, Instagram, etc.):
14. Gender:
Male
Female
15. Marital Status at Time of Donation:
Single
Married
Divorced
Separated
Life Partner
Widowed
Unknown
16. Donor Candidate Type:
Biological, blood related Parent
Biological, blood related Child
Biological, blood related Identical Twin
Biological, blood related Full Sibling
Biological, blood related Half Sibling
Biological, blood related Other Relative
Non-Biological, Spouse
Non-Biological, Life Partner
Non-Biological, Unrelated: Paired Donation
Non-Biological, Unrelated: Non-Directed Donation (Anonymous)
Non-Biological, Living/Deceased Donation
Non-Biological, Unrelated: Domino
Non-Biological, Other Unrelated Directed Donation
Non-Biological, Other
17. Ethnicity/Race: (select all origins that apply)
American Indian or Alaska Native
American Indian
Eskimo
Aleutian
Alaska Indian
American Indian or Alaska Native: Other
American Indian or Alaska Native: Not Specified/Unknown
Asian
Asian Indian/Indian Sub-Continent
Chinese
Filipino
Japanese
Korean
Vietnamese
Asian: Other
Asian: Not Specified/Unknown
Black or African American
African American
African (Continental)
West Indian
Haitian
Black or African American: Other
Black or African American: Not Specified/Unknown
Hispanic/Latino
Mexican
Puerto Rican (Mainland)
Puerto Rican (Island)
Cuban
Hispanic/Latino: Other
Hispanic/Latino: Not Specified/Unknown
Native Hawaiian or Other Pacific Islander
Native Hawaiian
Guamanian or Chamorro
Samoan
Native Hawaiian or Other Pacific Islander: Other
Native Hawaiian or Other Pacific Islander: Not Specified/Unknown
White
European Descent
Arab or Middle Eastern
North African (non-Black)
White: Other
White: Not Specified/Unknown
18. Citizenship:
US Citizen
Non-US Citizen/US Resident
Non-US Citizen/Non-US Resident, Traveled to US for Reason Other Than Transplant
Non-US Citizen/Non-US Resident, Traveled to US for Transplant
Country of Permanent Residence: ___________________________
Year of Entry into U.S.: _____________________________
19. Highest Education Level:
None
Grade school (0-8)
High school (9-12) or GED
Attended college/technical school
Associate/Bachelor degree
Post-college graduate degree
Unknown
20. Does the Candidate have health insurance?
YES
NO
UNKNOWN
21. Working for Income:
YES
If Yes (check one):
Working Full Time
Working Part Time due to Disability
Working Part Time due to Insurance Conflict
Working Part Time due to Inability to Find Full Time Work
Working Part Time due to Donor Choice
Working Part Time Reason Unknown
Working, Part Time vs. Full Time Unknown
NO
UNKNOWN
If Not Working, Reason (check one):
Disability
Insurance Conflict
Inability to Find Work
Donor Choice - Homemaker
Donor Choice - Student Full Time/Part Time
Donor Choice - Retired
Donor Choice - Other
UNKNOWN
22. Household Income:
$0 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $44,999
$45,000 to $54,999
$55,000 to $74,999
$75,000 to $99,999
$100,000 or above
Refused
Don’t know
23. Number of individuals living in the household: ___
Date of initial in-clinic screening for living donation: _____________
24. Pre-Donation Height and Weight
Height: ___ ft ___ in, or ___ cm
Weight: ___ lb, or ___ kg
25. History of Cancer (check all that apply):
NO
Lip
Other oral cavity/pharynx
Esophagus
Stomach
Colon and rectum
Anus
Liver
Pancreas
Lung
Melanoma
Squamous Cell Skin
Breast
Uterine Cervix
Corpus and Uterus
Prostate
Testis
Urinary Bladder
Kidney and Renal Pelvis
Brain and Other Nervous System
Thyroid
Hodgkin Lymphoma
Non-Hodgkin Lymphoma
Myeloma
Leukemia
Other, Specify:___________________
Cancer Free Interval: ___ years
26. History of Tobacco Use:
YES
NO
If YES,
Number of cigarettes per day: ____
__________ Number of years smoked: ______ (Pack years will auto-calculate.)
Duration of Abstinence from Cigarettes:
None, still smoking
0-2 months
3-12 months
1.1-3.0 years
3.1-5.0 years
>5.0 years
UNKNOWN
27. Other Tobacco Used:
YES
NO
UNKNOWN
28. History of Marijuana Use (check one):
Never
More than 5 years ago
Occasional use
Regular use
Declined or do not know.
29. Diabetes:
YES
NO
UNKNOWN
Treatment of Diabetes (check all that apply):
Insulin
Oral Hypoglycemic Agent
Diet
None
30. Is Candidate currently taking a cholesterol-lowering medication?
NO
YES, indicate either or both:
Statin
Other cholesterol-lowering medication
UNKNOWN
31. Was the Candidate ever told by a doctor or other health professional that he/she has/had hypertension (check one):
NO
≤5 YEARS
6-10 YEARS
>10 YEARS
UNKNOWN DURATION
UNKNOWN
If history of hypertension, is/was medication used to control blood pressure (check one):
None
1 medication for blood pressure
2 medications for blood pressure
More than 2 medications for blood pressure
UNKNOWN
32. Clinic Blood Pressure at the time of donor evaluation:
Systolic: ___ mm Hg
Diastolic: ___ mm Hg
33. 24-hour Ambulatory Blood Pressure obtained (check one):
Yes
No
34. Cholesterol and Glucose:
Total cholesterol: ___ mg/dL
High density lipoprotein (HDL) cholesterol: ___ mg/dL
Low density lipoprotein (LDL) cholesterol: ___ mg/dL
Triglycerides: ___ mg/dL
Fasting blood glucose: ___ mg/dL
35. Donation Information
Organ candidate will donate:
Liver
Kidney
Date of Donation:
Date of Decision to Not Donate:
Date of donation:
36. Does registrant agree to be contacted by LDC in the future?
Yes
No
L1. Total Bilirubin: ___ mg/dL
L2. SGOT/AST: ___ U/L
L3. SGPT/ALT: ___ U/L
L4. Alkaline Phosphatase: ___ units/L
L5. Serum Albumin: ___ g/dL
L6. Serum Creatinine: ___ mg/dL
L7. INR: ___
L8. Platelet Count: ______per microliter (mcL)
L9. Liver Biopsy:
NO (not done)
YES
% Macro vesicular fat: ___ %
% Micro vesicular fat: ___ %
L10. Did the Candidate ever have hepatitis, jaundice or elevated liver tests, or was the Candidate ever told by a health care provider that he/she had hepatitis, jaundice or abnormal liver tests?
YES
NO
UNKNOWN
L11. In the past 12 months, how often did the Candidate drink any type of alcoholic beverage? How many days per week, per month, or per year did the Candidate drink? Enter ‘0’ for never. Enter
|__| days per week, or
|__| days per month, or
|__| days per year.
Declined or don’t know
L 12. In the past 12 months, on those days that the Candidate drank alcoholic beverages, on the average, how many drinks did the Candidate have? Enter
|__|number of drinks, and if less than 1 drink, enter ‘1’.
Declined or don’t know
K1. Urine Albumin-Creatinine Ratio: ___ mg/g
K2. Serum Uric Acid: ___ mg/dL
K3. Serum Creatinine: ___ mg/dL
K4. APOL1 risk if Candidate is African American (check one):
0 risk variants
1 risk variant
2 risk variants
Not measured
UNKNOWN
K5. Family history of kidney disease (check one):
NO
Biologic parent
Child
Brother or sister
Other blood relative
UNKNOWN
Type of kidney disease in the family (check all that apply):
Kidney disease known to be caused by diabetes
Kidney disease known to be caused by high blood pressure
Autosomal dominant polycystic kidney disease (ADPKD or PKD)
Alport syndrome or thin basement membrane disease/nephropathy
Atypical hemolytic uremic syndrome (aHUS)
Fabry disease
Familial focal segmental glomerulosclerosis
Other hereditary kidney disease
None of the above
UNKNOWN
K6. Has a doctor or other health professional ever told the Candidate that he/she had gout?
YES
NO
UNKNOWN
K7. Family history of diabetes (check one):
NO
Biologic parent
Child
Brother or sister
UNKNOWN
K8. Has a doctor or other health professional ever told the Candidate that he/she had kidney stones?
YES
NO
UNKNOWN
If yes, how many times has the Candidate passed a kidney stone (choose one)?
0 (never)
1
2
3-5
>5
UNKNOWN
Most recent kidney stone:
Never
< 2 years ago
2-5 years ago
5-10 years ago
>10 years ago
K9. Have you ever been pregnant? Y/N/Male
During any pregnancy:
Was the Candidate ever told by a doctor or other health professional that she had diabetes, sugar diabetes or gestational diabetes? Please do not include diabetes that candidate may have known about before the pregnancy:
YES
NO
UNKNOWN
Was the Candidate ever told by a doctor or other health professional that she had Gestational Hypertension?
YES
NO
UNKNOWN
Was the Candidate ever told by a doctor or other health professional that she had Preeclampsia (Hypertension with Proteinuria during Pregnancy)?
YES
NO
UNKNOWN
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Nan Booth |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |