Living Kidney Donor Screening

We appreciate your interest in living kidney donation and ask that you answer the following questions to begin the process. Our living donor team will contact you within 10 business days when our medical team has made a decision about the next steps. If you have any questions please call us toll-free at 800.401.4444 or 402.559.5000. Our business hours are 8 a.m. to 4 p.m. CST. All information below will be kept secure and only used to determine if you meet initial requirements to be a living kidney donor.

Intended Recipient Information

Intended Recipient’s First Name

Intended Recipient’s Last Name:

Intended Recipient’s Date of Birth, if you happen to know it

Enter your information below

Relationship to Recipient

Example: sister, brother, aunt.

Have you been a patient at Nebraska Medicine?

Yes No

Date of Birth

(Must be at least 19 years old.)

Country of Citizenship

Were you born outside of the U.S.?

Yes No

Have you ever lived outside of the U.S.?

Yes No

Please list your Primary Care provider (your local doctor)

If employed, describe your work

Please describe your employment status

Height

in feet and inches

Have you ever been diagnosed with any of the following?

Blood sugar problem or Diabetes?

Yes No

Tuberculosis?

Yes No

High blood pressure?

Yes No

If yes, list high blood pressure medication(s)

If yes, please describe

Have you ever had an allergic reaction to IV contrast dye?

Yes No

Have you ever had kidney stones?

Yes No

When was your last kidney stone?

Have you ever had an urinary tract infections?

Yes No

When was your last urinary tract infection if when

Has a doctor ever told you that you had blood in your urine?

Yes No

When was the last time a doctor told you about blood in your urine?

Have you ever had cancer?

Yes No

If yes, please list the type of cancer and approximate date

Have you ever been told you have heart or lung disease?

Yes No

If so, which one?

Heart disease Lung disease

Have you ever had complications related to pregnancy, ie miscarriages, gestational diabetes, gestational hypertension

Please list all surgeries you’ve had and the approximate date(s)

Please list any other health issues you’ve had that aren’t listed above

Does anyone in your family have Polycystic Kidney Disease

Yes No Unkown

If yes, how are they related to you?

(Example: Mother, brother, paternal aunt, etc.)

Who in your family has had kidney disease

Who in your family has had high blood pressure?

Who in your family has had Diabetes

Please list any other major illnesses your family members have had

(Example: Cancer, Mother; Diabetes, Brother, etc.)

Do you smoke any tobacco products now?*

Yes No

Are you willing to quit completely?

Yes No

How many alcohol drinks do you have per week?

Have you ever used illegal drugs?

Yes No

If yes, please list drugs and approximate dates used

Please list all your prescribed medications as well as over the counter medications and vitamins with dosage, frequency and reason why

Can you climb two flights of stairs?

Yes No

Internal Exchange Donations

In the event you are found to be incompatible with your recipient, would you be willing to be part of an internal exchange? Kidney paired donation transplant enables two incompatible recipients to receive healthy, more compatible kidneys. <div id='paired-exchange-icon'></div>

Yes No