Transplant Center
Rhode Island Hospital

Donor Evaluation Questionnaire

Thank you for your interest in Living Donor Kidney Donation at Rhode Island Hospital. We are committed to providing treatment options to our patients living with and managing end stage renal disease. A kidney from a live donor is the best treatment option, as these kidneys function better and last longer than kidneys from a deceased donor.

Who can be a donor?

  • Related or unrelated to Recipient
  • Minimum age 18.
  • Free from
    • Diabetes
    • Uncontrolled high blood pressure
    • Active cancer
    • Kidney disease or recent kidney stones
    • Chronic pain, or infection.
  • Healthy weight
  • Adequate social support, stable mental health and financial security.
  • Active health insurance.

Patient Information

Address
Phone Number
Insurance Information
Do you currently have health insurance?
Physician Information
Additional Care Providers
If none put "NA"
Employment History
If none put "none"
If none put "none"
If none put "none"
If Disabled
Medical
Medical History Checklist

Please check any of the following that you have had in the past or suffer from now

Surgical History
1 to 10, with 10 being the worst. Put 0 if you do not experience pain.
How is your pain managed?
Current Medications
Please include any over the counter drugs, vitamins or supplements. You may attach your medications list as a file at the end of this questionnaire.
Allergies
Family Medical History
Family Medical History Checklist
Alcohol History
Please answer honestly. All answers are confidential.
Smoking History
Please answer honestly. All answers are confidential.
Substance Abuse History
Please answer honestly. All answers are confidential.
Substance Checklist
Please check any of the substances below that you have used, even if it was only once.
Recipient Information
Acknowledgement
I attest that the information provided to the Division of Organ Transplantation is true to the best of my knowledge. I have been informed about the program’s purpose for use of this information and have been given the opportunity to ask questions. I understand that Rhode Island Hospital Division of Organ Transplantation is required by law to maintain the privacy/confidentiality of my health information. By typing your name below, you attest to the statement above and that your typed name will constitute your signature on this form.
Type your full name
Interpreter Services
Rhode Island Hospital will provide interpreters for patients and family. If you need one, please indicate language.