Are You Eligible to Be a Living Kidney Donor?

Thank you for considering donating the gift of life at the University of Chicago Medicine. Please complete the following confidential form to help determine if you are eligible to donate a kidney.

* Indicates a required field
* 1. Gender
Male Female
 
* 2. Height, Weight
Height:   ft.   in.
Weight: lb.
Calculated BMI:
 
* 3. Race/Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic of Latino
Native Hawaiian or Other Pacific Islander
White or Caucasian
Other
 
  4. Zip Code
 
* 5. Do you have high blood pressure?
Yes No
* 6. Do you take multiple medications for high blood pressure?
Yes No
* 7. Do you have high blood sugar/diabetes?
Yes No
* 8. Are you taking medication to treat high blood sugar/diabetes?
Yes No
* 9. Have you ever had cancer?
Yes No
* 10. Do you have a history of heart problems, such as clogged arteries, heart attack or stroke?
Yes No
* 11. Have you been diagnosed with an autoimmune disease, such as lupus or rheumatoid arthritis?
Yes No
* 12. Do you have a lung disease, such as emphysema or COPD (not including asthma)?
Yes No
* 13. Are you willing to donate a kidney?
Yes No
 

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