The Kidney and Pancreas Transplant Center

Physician Referral: 1-888-MD-RWJUH Physician Referral: 1-888-MD-RWJUH
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Note: All fields are required

Patient Information

First Name(Legal Name): Last Name:
Address: City:
Zip: State:
Phone Number: Cell Number:
(Can we leave a message if you do not answer?)  
Please contact me: Email:
Gender:     Date of Birth:
(mm/dd/yyyy)
Recipient's Name: Relationship to Recipient:

Recipient Aware of your interest to donate:

 

Medical History

Height: Feet: Inches: Weight (lbs): BMI:
Blood Type:(If Known)    
Name of Primary Care Doctor: Date of last physical:
Did you ever have or been treated for a kidney stone?  
     If yes, the number of episodes?    
Do any blood relatives have a history of kidney stones?  
Were you ever treated for a urinary tract infection (UTI)?  

Are you currently being treated for high blood pressure?

 
     What is your typical BP?    
Do you take blood pressure medication?  
     If yes, name and dosage:    
Have you ever been pregnant? How many?  
Were you treated for High Blood Pressure during pregnancy?  
Blood sugar problems/Diabetes?  
Blood sugar problems/Diabetes during pregnancy:  
     If yes, please explain:
Have you ever had Cancer?    
     If yes, Type of cancer: Treatment:
Do you have heart problems?  
Did you ever have an echocardiogram or stress test?  
     If yes, please explain:
Do you have any bleeding problems or bleeding disorders?  
     If yes, please explain:
Have you ever been told that you have Hepatitis or liver problems?  
     If yes, please explain:
Have you ever had depression, anxiety, bipolar, schizophrenia?  
     If yes, please explain:

Surgical History

Please list surgeries:

Year/age:Reason

Hospitalizations:

Year/age:Reason

Additional Information:

Please list all your Current Medications: Prescription & Over the Counter (please include herbals and nutritional supplements):
Have you discussed your interest in kidney donation with your family/significant other?