Kidney Transplant Pre-Evaluation Questionnaire Form
Please complete this questionnaire to assist with your kidney transplant pre-evaluation. Answer all questions as accurately as possible.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Have you ever been diagnosed with high blood pressure (hypertension)?
*
Yes
No
Not sure
Do you have a history of diabetes?
*
Yes
No
Not sure
Are you currently taking any prescribed medications?
*
Yes
No
Do you smoke or use tobacco products?
*
Yes
No
Former user
Do you have any known allergies?
*
Yes
No
Have you previously undergone any major surgeries?
*
Yes
No
Please provide any additional relevant information for your pre-evaluation (optional)
Submit
Should be Empty: