*Legal name

*Date of birth

*Gender *Gender Choose not to disclose Female Male Other Transgender Female / Male-to-Female Transgender Male / Female-to-Male

*Race *Race Asian / Pacific Islander Black or African American Hispanic or Latino Native American or American Indian White Other

Religion Religion Buddhist Christian Hindu Jehovah Witness Jewish Muslim Sikh No religion Other

Marital status Marital status Married Separated Divorced Widowed Never Married

Children Children Yes No

Occupation

*Address

*City

*State *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming

Zip code

Please provide at least one phone number in either the home, work or cell phone fields below:

Home phone

Work phone

Cell phone

Can we leave messages on your:

Home phone? Home phone? Yes No

Work phone? Work phone? Yes No

Cell phone? Cell phone? Yes No

*Can we communicate with you by email? *Can we communicate with you by email? Yes No

*Do you have a preference in how we communicate with you? *Do you have a preference in how we communicate with you? Home Phone Cell Phone Work Phone Email Postal Mail No Preference

*Height

*Weight

*Are you taking any medications? *Are you taking any medications? Yes No

List of medications

Primary care physician

Physician's address

Physician's phone

*Surgical history (if none, write N/A)

*Allergies

Blood type Blood type O A B AB Not Sure

*Do you smoke? *Do you smoke? Yes No

*Do you drink alcohol? *Do you drink alcohol? Yes No

*Do you members of your family have kidney problems or diabetes? *Do any members of your family have kidney problems or diabetes? Yes No

Have you ever had any of the following?

Bladder infection	Pancreatitis
Kidney infection	Kidney stones
Liver disease/ Hepatitis	Blood disorder/ Anemia
Cancer	Bleeding problems
Lung disease	Herpes
Asthma	Sexually transmitted disease
Heart problems	Gout
Tuberculosis	Diabetes
High blood pressure	Stroke
Drug use	Psychiatric problems

*Do you have a recipient you would like to donate to? *Do you have a recipient you would like to donate to? I do not have a recipient and want to learn about non-directed kidney donation to someone in need of a kidney transplant I have a recipient that I want to donate to