Patient Information
Address
Phone Number
Relationship
If not applicable, put "N/A"
Emergency Contact
Cultural Background
If nowhere put "NA"
Insurance Information
Physician Information
Additional Care Providers
If none put "NA"
Education and Work History
If none put "none"
If none put "none"
If none put "none"
If Disabled
If unemployed put "unemployed"
Transportation
Name, relationship
Medical
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.
Systems Review
Please check any of the following that you have recently experienced
Additional Systems Review Information
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
Please list any allergies you have to food and/or medications
Family Medical History
Gynecological History
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.
Please check any of the substances below that you have used, even if it was only once.
Living History
Additional testing may be necessary.
Pets and Animal Exposure
Living Donor Increased Risk Screening Tool
Your answers to the following questions are needed to assess your risk for infections that can spread to the recipient of a kidney. Your responses will be kept confidential from the recipient, your family, your insurance company, and all others not involved in your medical care. Answer the following questions honestly; a “yes” does not mean that you cannot donate a kidney.
Personal Health History
In the past 12 months:
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.