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: ______
Name: ______Telephone Number: ______
Name: ______Telephone Number: ______
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 ______□ Brother or □ Sister ______
□ Male or □ Female Child ______
□ 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.)
______