Transplant candidate questionnaire Contact details First name* Last name* 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 Occupation Job Preferred language HebrewEnglishArabicFrenchRussian Contacts Contact Name Proximity to the contact Mobile contact Medical information Blood type ---OABBA Height cm* Weight* The cause of kidney failure* Dialysis type ---Homodialysis (at home)Peritoneal (hospital) Starting a dialysis process In which hospital are you registered? selectHadassahBellinsonShebaIchilovRambamSoroka Kupat Holim ---MaccabiLeumitclalitmeuhedet Is there a doctor from the transplant center who knows you personally? If so, who? Have you had a kidney transplant before? yesno Previous transplant date Do you have antibodies? Is the father eligible for donation? ---Not testedTested and found unfitTested and found fit Is there an impediment for the father to donate - detail* What is the reason that the father is not eligible to donate - detail* Why is the father not tested? Detail* Is the mother eligible to donate ---Not testedTested and found unfitTested and found fit Is there any impediment to the mother donating - detail* Why the mother was not found eligible to donate - detail* Why was the mother not tested? Detail* Are there any children who are eligible to donate a kidney ---Not testedTested and found unfitTested and found fit Is there an impediment to the child / children donating, detail* Why the child / ren were not found eligible to donate - detail* Why is the child / children not tested? Detail* Is there a spouse eligible for donation ---Not testedTested and found unfitTested and found fit Is there a prohibition for the spouse to donate - detail* What is the reason that the spouse is not eligible to donate - detail* Why is the spouse not tested? detail* Are there any sibling (s) eligible for donation ---Not testedTested and found unfitTested and found fit Is there an impediment for brothers / sisters to contribute?- detail* Why the brothers / sisters were not found eligible to donate - detail* Why is the sibling not tested? detail* Comments, clarifications Comments, clarifications Special requests: I hereby confirm that I am aware that registering with Matnat Chaim does not obligate Matnat Chaim to find a kidney donor.* I hereby confirm that I have not been offered nor do I intend to offer any monetary or other compensation for a kidney donation. The donation is altruistic and the only compensation is reimbursement of expenses that the donor receives in accordance with the Organ Transplantation Law.*. I hereby declare that I am aware that altruistic kidney donation is only possible after the options of donors from the immediate family have been exhausted*. Please leave this field empty. Send
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