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Could You Be Antonio's Match?

Living Donor Questionnaire

Fill this out online instead of printing a PDF. When you submit, your answers go directly by email to Prisma Health's Living Donor Coordinator — nothing is stored on this website. A copy of your answers is also emailed back to you for your records.

Prefer paper? Download the blank PDF instead.

Your Information

Social Security Number
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Sent by email directly to the Living Donor Coordinator, the same as the paper form.
Gender
Preferred Contact
Do you currently have health insurance?

Recipient Information

Have you met the intended recipient?
Does your recipient know you are considering donation?
What is your relationship to the recipient?

Health History

Weight Unit
Have you ever been told you have high blood pressure?
Have you ever been told you have diabetes?
How many, if any, family members are diabetic?
Have you ever been told you have arthritis?
Have you ever been told you have lupus?
If female, have you ever been pregnant?
How many pregnancies?
Any gestational diabetes or pre-eclampsia?
Have you ever been told you have kidney problems?
Have you ever had a kidney stone?
Have you had a heart attack in the past?
Have you ever had heart surgery or stents?
Have you ever been told that you had cancer?
Type of cancer/treatment:
Have you had any abdominal surgeries in the past?
If so, what type of surgery?
Have you ever been hospitalized for a psychiatric condition?
Have you ever attempted to harm yourself or others?
Do you currently use tobacco products?
If former smoker, for how many years and how much?
Do you drink alcohol?
If so, how much and how often?
In the past year, have you used any recreational or illegal drugs?
Or used a prescription medication for a non-medical purpose?

Medications

Include over-the-counter medications, supplements, and herbs.

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