One Chart | Patient - Living Kidney Donor Screening

We appreciate your interest in living kidney donation. Please answer the following questions to begin the screening process. Someone from our living donor team will contact you within 7-10 business days to discuss the living kidney donation process and donor eligibility.

If you have any questions, please call us toll-free at 800.401.4444 or 402.559.5000. Our business hours are Monday through Friday, 8 a.m. to 4 p.m. CST. All information provided below will be kept secure and used only to determine whether you meet initial requirements to become a living kidney donor.

Please fill out the form below

Section 1: Personal Information

1. First name

2. Middle initial

3. Last name

4. Date of birth

Donor must be at least 19 years old.

5. Address

6. City

7. State

8. ZIP code

Enter a 5-digit ZIP code.

9. Email address

10. Primary phone number

11. Primary phone type

Home Cell Work

12. Alternate phone number

13. Alternate phone type

Home Cell Work

14. Primary care provider (your local doctor) name, address and phone number

15. Do you have health insurance? If yes, please provide the name of the insurance provider and ID number

16. Sex

Male Female I do not wish to answer

17. Race or ethnicity

Section 2: Social History

18. Marital status

19. Are you employed?

Yes No

20. Employment status

21. If you selected Other, please describe your employment status

22. Do you use any nicotine or vape products? If yes, please describe and indicate whether you are willing to quit completely

23. How many alcoholic drinks do you have per week?

24. Have you ever used illegal drugs?

Yes No

Section 3: Medical History

25. Weight (in pounds)

26. Height (in feet and inches)

27. Please list your prescribed medications, over-the-counter medications and vitamins you take. Include dosage, frequency and reason

28. Blood sugar problem or diabetes?

Yes No

29. HIV?

Yes No

30. High blood pressure?

Yes No

31. Allergies?

Yes No

32. Have you ever had kidney stones?

Yes No

33. If yes, please describe how many and when

34. Have you ever had cancer?

Yes No

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

Yes No

36. Please list all surgeries you have had and the approximate date(s)

37. Please list any health issues you have had that are not listed above

38. Does anyone in your family have Polycystic Kidney Disease?

Yes No Unknown

39. Does anyone in your family have kidney disease? If yes, please describe

40. Does anyone in your family have high blood pressure? If yes, please describe

41. Does anyone in your family have diabetes?

42. Please list any other major illnesses your family members have had

Example: cancer, mother; diabetes, brother

43. Who is your intended recipient, and what is your relationship to them?