One Chart | Patient - Living Kidney Donor Screening

We appreciate your interest in living kidney donation. Please answer the following questions to begin the process.

A member of our living donor team will contact you within 7 to 10 business days to discuss the living kidney donation process and kidney donor patient selection.

If you have any questions, please call us toll-free at 800.401.4444 or 402.559.5000. Our business hours are from 8 a.m. to 4 p.m. CST.

All information you provide will be kept secure and only used to determine if you meet initial requirements to become a living kidney donor.

Please fill out the form below

Section 1: Intended recipient information

1. Who do you plan to donate to, and what is your relationship to this person?

2. Please provide the person's first and last name and date of birth, if known. If you are applying to be an anonymous donor, please enter N/A.

Section 2: Personal information

3. First name

4. Middle initial

5. Last name

6. Date of birth

Must be at least 19 years old.

7. Have you ever been a patient at Nebraska Medicine?

Yes No

8. Address

9. City

10. State

11. ZIP code

Enter a 5-digit ZIP code.

12. Are you a U.S. citizen?

Yes No

13. Were you born outside of the U.S.?

Yes No

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

Yes No

15. Primary phone

16. Primary phone type

Home Cell Work

17. Alternate phone

18. Alternate phone type

Home Cell Work

19. Please list your primary care provider (your local doctor): Name, address, and phone number

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

21. Sex

Male Female I do not wish to answer

22. Race/Ethnicity

Section 3: Social history

23. Marital status

24. Are you employed?

Yes No

25. Employment status

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

27. Do you smoke, vape, or use any nicotine or tobacco products now?

Yes No

28. If you selected Yes, are you willing to quit completely?

Yes No

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

30. Have you ever used illegal drugs?

Yes No

Section 4: Medical history

31. Blood type

32. Weight (in pounds)

33. Height (in feet and inches)

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

Have you ever been diagnosed with any of the following:

35. Blood sugar problem or diabetes?

Yes No

36. HIV?

Yes No

37. Hepatitis?

Yes No

38. Tuberculosis?

Yes No

39. Meningitis?

Yes No

40. High blood pressure?

Yes No

41. Allergies?

Yes No

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

Yes No

43. Have you ever had kidney stones?

Yes No

44. If yes, please describe how many and when.

45. Have you ever had urinary tract infections?

Yes No

46. Has a doctor ever told you that you have blood in your urine?

Yes No

47. Have you ever had cancer?

Yes No

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

Yes No

49. Please list all surgeries you've had and the approximate date(s):

50. Please list any health issues you've had that aren't listed above:

51. Can you climb two flights of stairs?

Yes No

Section 5: Family history

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

Yes No Unknown

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

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

55. Does anyone in your family have diabetes? If yes, please describe.

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

Example: Cancer, mother; diabetes, brother, etc.

Internal exchange donations

57. If testing shows you are not a compatible match for your intended recipient, would you be willing to participate in a kidney exchange? A kidney exchange matches donor-recipient pairs with other pairs in a similar situation. This allows each recipient to receive a healthy, compatible kidney.

Yes No