Ucla Form 500575 – Fill Out and Use This PDF

LIVING KIDNEY DONOR INTAKE FORM

Date of Intake________________ Reviewed by___________________

Donor Name: ________________ ____________________ __________ M / F Donor UCLA # if app.):

					___________________________
	Last	First	Middle
Home			City:			State:
Address:			Zip:

Relation to Recipient: ______________ SS#: _______________ Email Address: ____________________

Home Phone #: (_______)________________ Alternate Phone #: (_______)_________________

Work Phone#: (_______)___________________

Age: _______ Date of Birth: ____________ Marital Status: ____________	Citizenship Status:__________
Race: _____________________ Primary Language____________________	Speak English? Yes / No

Donor’s Maiden Name (if app): ________________ Mother’s Maiden Name: _________________________

Highest Education Level: _____________ Employer Name: __________________ Job Title: ___________

Name of Person you are donating your kidney to: ____________________________________

Date of Birth: ___________________

*OFFICE USE ONLY*

(ADULT/PEDS) Recipient’s MRN: __________Recipient’s ABO: _________ Last CTA: _____________

Status: _________________________ Recipient’s Diagnosis: _____________________________________

Recipient’s Insurance:________________________________________________

- SEE PAGE 2 –

UCLA Living Donor Line: 866-672-5333	FAX THIS FORM TO: 310: 983-3628	www.transplants.ucla.edu
UCLA Form #500575 Rev. (03/11)		Page 1 of 2

LIVING KIDNEY DONOR INTAKE FORM

Donor’s ABO: __________ Ht: __________ Wt: __________

Medications (prescription and over-the-counter): ___________________________ Allergies: _______________

Blood Sugar Problems (yourself or family): __________________________ During pregnancy? ____________

High Blood Pressure (yourself or family): ___________________________ During pregnancy? ____________

Heart Problems (yourself or family): ____________________________________________________________

Any history of melanoma?: __________ If yes, how long ago were you diagnosed?: _____________________

Kidney Stones or Kidney Problems (yourself or family): ____________________ Cancer: ________________

Urine or Kidney Infections: ___________________________ Liver Problems or Hepatitis:________________

Alcohol / Tobacco/Drug Use: ________________________ Mental Health Problems: ____________________

Hospitalizations/Surgeries/Other Health Problems: ________________________________________________

Any bleeding problems? _____________________________________________________________________

Have you been worked-up as a potential donor at another transplant center, and if so where? _______________

Have you ever been incarcerated, and if so how long ago? __________________________________________

When was your latest: Pap Smear (Females only) ___________ Mammogram (Females > 40) ______________

Colonoscopy ( > 60) _______________

Have you discussed your intention to donate with your family/significant other? _________________________

Do you have health insurance? _______Who will take care of you after the surgery? _____________________

Signature of Donor _________________________________________________ Date ________________

Signature of Person Filling Out

Report (if other than donor)
Print Name	Date ______________

UCLA Living Donor Line: 866-672-5333	FAX THIS FORM TO: 310: 983-3628	www.transplants.ucla.edu
UCLA Form #500575 Rev. (03/11)		Page 2 of 2