Kidney donor questionnaire Contact details First name* Last name* gender* ---femalemaleOther Teudat Zehut or Passport Number* Date of birth* Address City* Country ZIP code Mobile phone* Telephone Fax Email* Family status ChooseSingleMarriedWidow/er Number of children citizenship OtherCircassianDruzeChristianMoslemJewish citizenship-section traditionalsecularreligiousorthodox Occupation Job Have other family members donated NoYes Details of family members: Preferred language HebrewEnglishArabicFrenchRussian Medical information Blood type ---OABBA Height cm* Weight* Kupat Holim ---MaccabiLeumitclalitmeuhedet 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)?* NoYes Detail kidney disease in the past Have you had any kidney stones?* NoYes Detail of kidney stones Have you been hospitalized?* NoYes Detail of hospitalizations Have you had any surgeries in the past?* NoYes Detail past surgeries Do you have heart or lung dysfunction?* NoYes Details of lung or heart dysfunction Do you regularly take medication?* NoYes Detail of medications Do you suffer from allergies?* NoYes Allergy details Do you smoke?* NoYes How many years have you been smoking? Number of cigarettes a day Have you smoked before?* NoYes How many years have you smoked? Number of cigarettes you smoked a day Do you have family members who have diabetes?* NoYes Details about diabetes in the family Do you have family members with kidney disease?* NoYes Details of family members suffering from kidney disease Are there family members with kidney stones?* NoYes Detail family members with kidney stones Were you born before the 36th week of pregnancy?* NoYes In what week of pregnancy? Are there family members with clotting problems (leg vein blockage / recurrent miscarriages, need for blood thinners)?* NoYes Details of family members with clotting problems Special requests: What has most influenced you to sign up for 'Matnat Chaim' ----Personal acquaintance with a kidney donorA magazine of the associationActivity on Facebook or another social networknewspaper articleAn article on TV or radiolectureA campaign of waiting for a transplantthrough transplanted/patientInternetacquaintancePlease leave this field empty. Is the donation intended for the benefit of a particular patient? If so, for whom? 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" Send
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