KIDNEY DONOR QUESTIONNAIRE

PERSONAL INFORMATION
DONOR LAST NAME CHINAZA DONOR FIRST NAME WISDOM

DATE 17TH October 2023 GENDER M

DONOR ADDRESS
2 Eyiowawi Street Ifako Agege

CITY Agege STATE Lagos ZIP

SPOKEN LANGUAGE Igbo _ OTHER LANGUAGE(S) English

CELL PHONE 08141616271 WORK PHONE 09058629378

DATE OF BIRTH 15th September 1999 AGE 24 HEIGHT 5.3

WEIGHT 60 kg

POTENTIAL DONOR TO:

EMEKA CHRISTOPHER

DATE OF BIRTH August 1987 AGE 36 HEIGHT 6.3 WEIGHT 80kg

RELATIONSHIP TO RECIPIENT Friend BLOOD TYPE O+

PART 1: DONOR MEDICAL INFORMATION

MEDICATIONS/DOSAGE HERBAL SUPPLEMENTS ALLERGIES TO

MEDICATIONS
 PART 2: DO YOU HAVE OR HAVE EVER HAD?
DIABETES NO HOW LONG

KIDNEY STONES NO HOW MANY TIMES?

CANCER NO WHERE

ACTIVE HEPATITIS NO _ LUPUS

HIV/AIDS NO CHRONIC LUNG DISEASE

HIGH BLOOD PRESSURE NO WHAT IS IT NOW

HEART DISEASE NO HIGH CHOLESTEROL

ARE YOU PREGNANT? OR TRYING TO CONCEIVE NO

GESTATIONAL DIABETES NO

PART 3: DO YOU HAVE OR EVER HAD?

ASTHMA NO ANEMIA NO
BLOOD TRANSFUSION NO SEIZURES NO
HEART MUMUR NO URINARY TRACT INFECTIONS _ NO
KIDNEY/BLADDER INFECTIONS NO PROTEIN IN URINE NO
BLOOD IN URINE NO
ALCOHOL NO AMT/FREQ
SMOKE NO AMT/FREQ
MARIJUANA NO AMT/FREQ
ILLICIT IV DRUG NO AMT/FREQ _
COCAINE NO AMT/FREQ
QUIT SMOKING WHEN?
DEPRESSION NO ANXIETY
PANIC ATTACKS NO PSYCHIATRIC DISORDERS NO
OTHER CHRONIC ILLNESS
NO
 PART 4: DONOR SURGICAL & HOSPITALISATION HISTORY
PLEASE LIST ANY SURGICAL PROCEDURES YOU HAVE HAD IN THE PAST

SURGICAL DATE REASON(S)

PROCEDURE PERFORMED

HAVE YOU EVER BEEN HOSPITALIZED FOR ANY REASON OTHER THAN THE
ABOVE SURGERY, IF SO LIST BELOW

REASONS FOR DATE OF DIAGNOSIS

HOSPITALISATION HOSPITALISATION

PART 5: HAS ANYONE IN YOUR FAMILY EVER HAD? (PLEASE

INDICATE RELATIVE, I.E MOTHER, FATHER, SISTER, BROTHER)
HIGH BLOOD PRESSURE NO WHO

HEART ATTACK/STROKE NO WHO

CORONARY ARTERY DISEASE NO WHO

DIABETES NO WHO

CANCER NO WHO
 PART 6: ADDITIONAL QUESTIONS
ARE YOU MARRIED? NO

IS YOUR SPOUSE AWARE OF YOUR INTEREST TO DONATE? YES

ARE YOU READY TO DONATE? YES

DO YOU HAVE ANY ADDITIONAL QUESTIONS ABOUT BEING A KIDNEY DONOR

WHERE WERE YOU BORN? ENUGU

WHERE DID YOU GROW UP? ABUJA

HOW MANY CHILDREN DO YOU HAVE?

AGES OF YOUR CHILDREN

WHO WILL TAKE CARE OF YOU AFTER YOUR KIDNEY DONOR

SURGERY? NURSE

HOW WILL YOU RATE YOUR FAMILY SUPPORT SYSTEM?

 EXCELLENT NO SUPPORT AGAINST DONATION

PART 7: ADDITIONAL QUESTIONS

WHAT IS YOUR HIGHEST LEVEL OF EDUCATION COMPLETED SSCE

ARE YOU CURRENTLY WORKING FOR INCOME? Yes

EMPLOYER GAPIN HOTEL

OCCUPATION Cheif