Donor Information - Demographics

The information gathered in this form is required to ensure your suitability as a donor. The questionnaire is based on the British Transplant Society Guidelines which are in place to minimise risk. It helps us start to understand whether there are any factors in your medical history and lifestyle that could affect your potential suitability to be a live kidney donor. We value your honesty with this process. The information will be used only for that purpose and will be kept strictly confidential at all times. It will only be shared with health care professionals involved in your assessment, and if assessed as suitable, your donation.

Once the questionnaire has been returned in full and you have been registered with the service, a member of the live donor nursing team will be in touch within 2 weeks.

For more information please visit : http://www.organdonation.nhs.uk/livingdonation
As part of the shared care agreement, the nursing team will liaise with your local GP practice. This is to ensure that you the healthcare professionals involve in your care have all the information available, to make a safe and appropriate decision on whether to proceed with the live kidney donor procedure.

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* 1. NHS Number (If Known)

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* 2. Name

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* 3. Date of birth

Date

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* 4. Gender

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* 5. Country of birth

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* 6. Ethnicity

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* 7. Full address (Including postcode)

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* 9. Telephone Number

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* 10. Can voicemail messages be left?

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* 11. What is the best time to call?

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* 12. Language

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* 13. Specific communication needs (e.g. hearing difficulties)

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* 14. Interpreter required?

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* 15. GP Contact Details

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* 16. GP Contact telephone phone number

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