Pre-Transplant Social History

THE CHRIST HOSPITAL

TRANSPLANT SOCIAL WORK

Pre-Transplant Social History

Donor Assessment

Please do not leave any questions unanswered. Take your time and answer them as fully as possible.

Name: ______DOB: ______

Address: ______SS#: ______

City: ______Home phone: (____)______-______

Zip: ______Cell phone: (____)______-______

Recipient______Citizenship ______

Name of your Primary Care Physician: ______

Doctor’s office phone number: (______)______-______

FAMILY/SOCIAL INFORMATION

Who lives in your home?

Name Age Relationship to you

______

Where were you born and raised? ______

Describe your family life growing up. ______

______

List all other family members outside the home. (Immediate and extended) Use other side if more space is needed.

Name Age Relationship to you

______

Please list people who give you emotional support. (Family, friends, pastor, etc.)

Name Relationship to you

RECOVERY PLAN

Kidney donation involves having a major surgery (nephrectomy). You will need a plan to have a successful recovery after your nephrectomy.

Please tell us:

Where will you stay once discharged from the hospital? ______

Who will be able to stay with you for the first few days after you are discharged from the hospital?

______

______

If you have young children, who will look after them, get them to school, etc.?

______

______

______

Do you have Advance Directives? (Living Will. Durable Power of Attorney.)

If not, would you like information about Advance Directives? ______

SPIRITUAL SUPPORT

Although having a nephrectomy is a very safe surgery it is, nonetheless, a major surgery and will put you at medical risk. People often turn to their source of spiritual support and guidance when in harm’s way. Do you a spiritual community? If so, what is it? Who do you turn to when you (or a loved-one) is in danger? ______

______

ACTIVITIES

Are you active in any clubs or social organizations? If yes, please list

1.______2.______

3______

What are your favorite things to do to relax and enjoy yourself?

1.______2.______3.______

EDUCATION/EMPLOYMENT

What was the last grade of school you completed? ______

Where did you go to school? ______

Are you currently employed? _____Yes _____No

If yes, what is the name of your employer? ______

Please describe in detail what you do at work. ______

How long have you worked there? ______

Have you discussed donating with employer? _____ Yes ____No

If yes, describe employers response:______

Do you have medical insurance? If so, what is it?______

Are you eligible for short-term disability /FMLA benefits? _____ Yes _____ No

Is your Spouse/S.O. employed? ____Yes ____ No

If yes, where? ______

TIME OFF FROM WORK

After your nephrectomy you may need to be off from work 4 – 6 weeks for your recovery. Do you have adequate sick/vacation time accrued to cover that much time away from your job?

Will being off from work create financial hardship for you and your family?______

If yes, how will you manage? ______

______

Who is dependent on you financially? ______

MEDICAL INFORMATION

Please list all past surgeries: ______

During your recovery did anyone help you out? If so, who______

______

HEALTH HABITS

Do you exercise regularly? If so, describe what you do. ______How well do you cope with stress? ______

Describe a time in your life that was very stressful. What was going on? ______

______

What did you do to help yourself cope with the stress? ______

______

Do you smoke? ____Yes ____No If yes, how much?______

Do you drink alcohol? _____Yes _____No

Have you ever been treated for alcohol abuse? _____Yes _____No

Do you smoke marijuana?______If so, how often?______

Have you ever used illegal drugs or misused prescription medicines?

____Yes ___No

If yes, what drugs did you use? ______

Have you ever been treated for substance abuse? ____Yes ____No

If yes, where were you treated and when? ______

Have you seen a counselor, psychiatrist, or therapist? ______Yes _____No

If yes, When?______

If yes, please briefly describe the circumstances and whether you found it helpful? ______

______

PERSONAL STATEMENT

What are your motivations for wanting to donate? ______

In what ways will donation affect your relationship with the recipient? Please describe. ______

______
______

______

Please list your four biggest worries about donating? 1.______2.______3.______4.______

Signature: Date:

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