Iowa Methodist Medical Center

Iowa Methodist Transplant Center

Kidney Recipient Health History Form

Personal Information
Full Name: ______□ Male □ Female

Date of Birth: ______Social Security Number: ______

Mailing Address: ______

City: ______State: ______Zip Code: ______

Home Telephone: ______Cell phone: ______Work phone: ______

Email address: ______

Race: ______Place of Birth: ______Are you a US Citizen? □ Yes □ No

Advance Directives

What is your CODE status? FULL or DNR (Do Not Resuscitate) (please circle one)

Are you willing to accept blood products? _____ Yes _____ No

Do you have a Durable Power of Attorney? _____ Yes* _____ No

Do you have a Living Will? _____ Yes* _____ No

*Please be prepared to provide a copy.

Emergency Contacts

Name: ______Telephone Number: ______

Health Care Providers Please provide a list of all of your healthcare providers:

Kidney Doctor: ______

Family Doctor: ______

Heart Doctor: ______

Diabetes Doctor: ______

Other Doctor: ______

Allergy History

Medication allergies: ______

Food or Environmental allergies: ______

Medical History Please check if you have any of the following conditions/symptoms:

___ Diabetes / ___ Peripheral Vascular Disease / ___ Bladder problems
___ High blood pressure / ___ Hearing difficulties / ___ Kidney infections
___ High cholesterol / ___ Vision difficulties / ___ Kidney stones
___ Lung disease / ___ Thyroid problems / ___ Liver disease
___ Sexually transmitted disease / ___ Bleeding disorder / ___ Chronic pain
___ Chicken pox / ___ Sleeping difficulties / ___ Depression/Anxiety
___ Shingles / ___ Cancer / ___ Blood transfusions
___ Heart attack / ___ Teeth or gum problems / ___ Previous transplant
___ Stroke / ___ Seizure Disorder / Dialysis Start Date: ______

Immunization and Preventative Health History When did you last have the following:

Tetanus ______Pneumonia ______Flu ______Hepatitis A ______Hepatitis B______

Dental Exam ______Eye Exam______Colonoscopy ______

(Women Only: Mammogram ______Pap smear ______

Surgeries/Injuries Please list any surgeries/injuries:

______

Social History

Marital Status: □ Single □ Married □ Divorced □ Widowed

Spouse/Significant Other’s name: ______Telephone:______

Maiden Name or any other name under which records may be kept:______

What is your highest level of education completed______

Are you currently working? □ Yes □ No If Yes, □ Full time or □ Part time?

Occupation______Employer______

Tobacco Use: _____No _____ Yes, how much/how long______

Alcohol Use: _____ No_____ Yes, how much/how often______

Recreational Drug Use: _____ No_____ Yes, how much/how often______

Can you perform your daily activities independently? _____ No_____ Yes If No, please explain ______

Do you exercise regularly? ______

Family History Age Current Health Status/Cause of Death_____

Father ______

Mother ______

Spouse ______□ Brother or □ Sister ______

□ Brother or □ Sister ______

□ Brother or □ Sister ______□ Brother or □ Sister ______

□ Male or □ Female Child ______

□ Male or □ Female Child ______□ Male or □ Female Child ______

(Please indicate if you or other family members are adopted.)

Do you know of anyone who may be interested in donating a kidney to you? _____ Yes _____ No

Have you ever received a blood transfusion? ______Yes ______No. If you answer yes to this question when did you receive blood and how many units did you receive______

Additional

Is there any additional information that you feel is important for us to know about your medical history or current situation?

______

Please bring the following to your evaluation:
ü Informed Consent
ü Completed Kidney Recipient Health History Form
ü Insurance Cards
ü List of Medications
ü Copy of Durable Power of Attorney and/or Living Will
(The Transplant Center will make copies for you if necessary.)

______