Kidney donor questionnaire

    Contact details

    First name*
    Last name*
    gender*
    Teudat Zehut or Passport Number*
    Date of birth*
    Address
    City*
    Country
    ZIP code
    Mobile phone*
    Telephone
    Fax
    Email*
    Family status
    Number of children
    citizenship
    citizenship-section
    Occupation
    Job
    Have other family members donated
    Details of family members:
    Preferred language HebrewEnglishArabicFrenchRussian

    Medical information

    In this section, you will be asked to fill in various medical data so that Matnat Chaim can check your initial suitability for kidney donation. By filling in the data, you give your consent in advance to-disclose the information to Matnat Chaim and to other related parties on its behalf, including the National Transplant Center, and authorize Matnat Chaim to carry out all the necessary inquiries in connection with the aforementioned and related data, for the purpose of checking your suitability for kidney donation.

    Blood type
    Height cm*
    Weight*
    Kupat Holim
    Do you suffer from any of the following? High blood pressureKidney DiseaseDiabetesObesityOther
    Details of diseases
    Have you previously suffered from kidney disease (such as blood in the urine, protein in the urine)?*
    Detail kidney disease in the past
    Have you had any kidney stones?*
    Detail of kidney stones
    Have you been hospitalized?*
    Detail of hospitalizations
    Have you had any surgeries in the past?*
    Detail past surgeries
    Do you have heart or lung dysfunction?*
    Details of lung or heart dysfunction
    Do you regularly take medication?*
    Detail of medications
    Do you suffer from allergies?*
    Allergy details
    Do you smoke?*
    How many years have you been smoking?
    Number of cigarettes a day
    Have you smoked before?*
    How many years have you smoked?
    Number of cigarettes you smoked a day
    Do you have family members who have diabetes?*
    Details about diabetes in the family
    Do you have family members with kidney disease?*
    Details of family members suffering from kidney disease
    Are there family members with kidney stones?*
    Detail family members with kidney stones
    Were you born before the 37th week of pregnancy?*
    In what week of pregnancy?
    Are there family members with clotting problems (leg vein blockage / recurrent miscarriages, need for blood thinners)?*
    Details of family members with clotting problems
    Special requests:
    What has most influenced you to sign up for 'Matnat Chaim'
    Is the donation intended for the benefit of a particular patient? If so, for whom?
    What Is your relationship to the patient?
    I hereby confirm that my decision to donate a kidney was made in a fully informed manner and without pressure from any external source.*
    I hereby confirm that I have not requested or received, nor do I have any intention of requesting or receiving any monetary or other compensation for the donation of my kidney (other than reimbursement of expenses as per the transplant law). My kidney donation is strictly altruistic, for the purpose of saving a life.*
    Approves receiving mailings from "Matnat Chaim"