Are You Eligible to Be a Living Kidney Donor?

* 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 medication for high blood pressure?	Yes No
* 7. Were you treated for high blood pressure during pregnancy?	Yes No
* 8. Do you have high blood sugar/diabetes?	Yes No
* 9. Are you taking medication to treat high blood sugar/diabetes?	Yes No
* 10. Have you ever had cancer?	Yes No
* 11. Do you have a history of heart problems, such as clogged arteries, heart attack or stroke?	Yes No
* 12. Have you been diagnosed with an autoimmune disease, such as lupus or rheumatoid arthritis?	Yes No
* 13. Do you have a lung disease, such as emphysema or COPD (not including asthma)?	Yes No
* 14. Are you willing to donate a kidney?	Yes No

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