Please print out the following using your browser's printer function and mail to Renal Transplant Program,U.T.M.B., 301 University Blvd.-RT 0262, Galveston, Texas 77555-0262.

QUESTIONNAIRE FOR TRANSPLANT EVALUATION

Date:______________________

The information in this questionnaire will be treated as confidential. It will be shared with members of the Transplantation Team only. The information in this questionnaire will assist us in evaluating you for a transplant.

Patient Type: (check one) Recipient_____ Donor_____
Donor for:_________________________________

Name (last):______________________(first):__________________(middle):_____________
Maiden Name:_____________________
Address:____________________________________________________________________
City:___________________________________ State:_____________ Zip Code: _________
Telephone Number Home:(____)_____________________ Work:(____)_________________

Date of Birth:_________________ Place of Birth: ______________________
Social Security Number:___________________________________________
Male ______ Female_______
Race: ____________________
Marital Status:___________________Spouse's Name:________________________________
U.S. Citizen: Yes _____ No_____ If no, explain:_____________________________________
Height:______________ Weight:______________ Weight 1 Year Ago:__________________

Medicare Number:______________________ Medicaid Number:_______________________
Texas Kidney Health Plan Number:_______________________________________________
Other Insurance (company):________________________(policy #)______________________
Name of insured______________________________

Occupation:____________________________ Full-time _____Part-Time______
Are you presently working? Yes _____No _______
What is the highest grade you completed in school?_________________
How many miles is it from your home to Galveston?_________________
How will you travel to Galveston? Car _____ Fly ______ Bus________

Nephrologist Name: _________________________________Phone__________________
Cause of Kidney Failure:_____________________________________________________
Have you ever had a kidney biopsy? Yes _____ No _______
If Yes, Date:_____________________ Name of Hospital:___________________________
Are you on dialysis? Yes ______ No ______
Type of Dialysis:_____________________________ Date of First Dialysis:______________ Dialysis Center:______________________________Phone #________________________
Dialysis Nurse:________________________________________________
Dialysis Days:________________________Time_____________________

Family History

Relative Age Health/Cause of Death
Father ________ _______________________________
Mother ________ _______________________________
Brother/sister ________ _______________________________
Brother/sister ________ _______________________________
Brother/sister ________ _______________________________
Brother/sister ________ _______________________________
Child ________ _______________________________
Child ________ _______________________________
Child ________ _______________________________
Child ________ _______________________________
Child ________ _______________________________

List all current medications:_________________________________________
_______________________________________________________________
_______________________________________________________________
Allergies: (Medications and Other Allergies) _______________________________________________________________
_______________________________________________________________
Immunizations:

Flu Shots: Yes_______ No: _______ Date:___________
Hepatitis Vaccine: Yes________ No:________ Date:___________
Pneumonia Vaccine: Yes________ No:_______ Date:___________
TB Skin Test: Pos.______ Neg. ______ Date:___________



Habits:

Smoking: Yes _________ No __________
Packs per day_______ How long? _________
Quit Smoking? Yes__________ No _________ Date:______________



Alcoholic Beverages:

Presently: Yes__________ No_________
How often? ____________
How much?____________
Past Use: Yes__________ No_________
How long?_____________
How often? ____________
How much?____________



Recreational Drugs: Yes__________ No___________
Type:_______________________Date_________________________
Type:_______________________Date_________________________
Type:_______________________Date_________________________



Please indicate whether you have ever had the following diseases

Hepatitis: Yes__________ No______________
Tuberculosis: Yes__________ No______________
Chicken Pox: Yes__________ No______________
Rheumatic Fever/Heart Disease: Yes__________ No______________
Arthritis/Rheumatism: Yes__________ No______________
Gonorrhea/Syphilis: Yes__________ No______________
Cancer: Yes__________ No______________
What type?_______________________
How long ago?____________________
How treated?_____________________
Are you diabetic? Yes______________ No______________
Age you became diabetic:______________
Do you take insulin? Yes______________ No______________
Age you began taking insulin:____________
Do you take pills to control sugar? Yes ___________ No______________
Do you have high blood pressure? Yes ___________ No______________
How long? ________________
How treated?________________________
Have you ever had a stroke? Yes_______ No_________ Date ___________



(Please indicate whether you have ever had trouble with the following)

Seeing double? Yes ___________ No______________
Seeing halo around lights? Yes ___________ No______________
Legally blind? Yes ___________ No______________
Hearing loss? Yes ___________ No______________
Ear Infections? Yes ___________ No______________
Ringing in ears? Yes ___________ No______________
Goiter? Yes ___________ No______________
Frequent sore throats? Yes ___________ No______________
Hoarseness? Yes ___________ No______________
Gum Problems (bleeding, sores, swelling)? Yes ___________ No______________
Sores in mouth? Yes ___________ No______________
Other dental problems? Yes ___________ No______________
Date of Last Dental Visit:___________________
Breast Lumps? Yes ___________ No______________
Discharge? Yes ___________ No______________
Pain? Yes ___________ No______________
Family history of breast cancer? Yes ___________ No______________

Which family member(s)?____________________________________________

Have you had a mammogram? Yes_________ No___________ Date __________
Do you still have menstrual periods? Yes_____________ No _____________
Age at onset of periods:_______________
Date of last pap smear:________________
How many pregnancies?_______________
How many live births?_________________
Cough that doesn't go away? Yes ___________ No_____________
Coughing up blood? Yes ___________ No_____________
Shortness of breath? Yes ___________ No_____________
Night sweats? Yes ___________ No_____________
Chest pain or pressure? Yes ___________ No_____________
Rapid heartbeat or fluttering? Yes ___________ No_____________
Have you ever had a heart attack? Yes ___________ No_____________ Date_____________
Have you ever had a pacemaker? Yes ___________ No_____________ Date_____________
Have you had a cardiac cath? Yes ___________ No_____________ Date_____________
Heart valve replacement? Yes ___________ No_____________ Date_____________
Heart bypass surgery? Yes ___________ No_____________ Date_____________
Vomiting blood? Yes ___________ No_____________
Gall bladder trouble? Yes ___________ No_____________
Blood in stool/black tarry stools? Yes ___________ No_____________
Hemorrhoids? Yes ___________ No_____________
Ulcers? Yes ___________ No_____________
What Type:_________________________ When? ______________________
Frequent headaches? Yes ___________ No_____________
Convulsions (seizures)? Yes ___________ No_____________
Paralysis or weakness? Yes ___________ No_____________
Dizzy spells? Yes ___________ No_____________
Depression? Yes ___________ No_____________
How much urine do you make per day? __ None or less than a cup
__ 1 cup to 1 quart
__ More than a quart
Kidney or bladder infections? Yes ___________ No______________
Pain on urination? Yes ___________ No______________
Blood in urine? Yes ___________ No______________
Kidney stones? Yes ___________ No______________
Problems emptying bladder? Yes ___________ No______________

What is your blood type?____________

Have you ever had a transfusion? Yes ___________ No______________
Are you willing to accept transfusions? Yes ___________ No______________
How many units of blood have you had in your lifetime?________________
Approximate date of last transfusion:_______________________________
Have you had a transplant? Yes________ No_________ Date_____________
Where?_______________________
Type:________________
Why did your transplanted kidney stop working?_______________________________
When did your transplanted kidney stop working?______________________________

List other operations and dates:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Have you been hospitalized for any other illness? Yes ___________ No______________
If yes, please give dates and hospital names, if known:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Any other information you believe is important for us to know about your medical history (for example, physical disabilities, limitations, handicaps, etc.):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Rev. 03/30/98

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