Kidney Transplant Questionnaire

Your Name:
Q1: Are you patient with kidney failure?
No, a friend or relative has kidney failure
Q2:How old is the patient?
Q3: Is there anyone who is interested in donating a kidney?(Living kidney donator)
must be at least 18 years old and no diabetes or high blood pressure
Yes No
Q4: What is blood type of the patient?
A B AB O Not sure
Q5: What is the primary cause of kidney failure?
Glomerulonephritis Diabetic Nephropathy IgA Nephropathy Hypertensive Nephropathy FSGS Nephrotic Syndrome Polycystic Kidney Disease Systemic Lupus Erythematosus (SLE) Purpura Nephritis
Q6: How long has the patient been on dialysis?
Q7: Choose if the patient has any of the following conditions:
Active or recently treated cancer
Poorly controlled HIV infections
Severe obesity (a body mass index greater than 40)
Current drug or alcohol abuse
Inability to remember
medicines Heart disease
None of the above
Q8: If the patient has had kidney transplant, choose if there exists any of the following signs of kidney rejection or complications
Hypertension swelling or puffiness Decreased urine output Pains or burning when urinating Prolonged nausea Lightheadedness Extreme fatigue Skin rash Abdominal pains Tenderness or redness at the surgical site Shortness of breath High blood cholesterol Infections Relapse of the primary disease Weakening of the bones
Q9: Do you plan to have a baby after kidney transplant?
Yes No
Q10: Has the patient had any blood transfusions?
Yes No
Q11: (Post-transplant only) List the medicines you are taking, including the names, dose and frequency of the medicines.
Q12: what information would you like to be given?

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