Living Donor Prescreen

Name

Email Address

Country

ZIP Code / Postal Code

Birthday

Height

Weight

Gender

Male Female

Do you currently have hypertension (high blood pressure)? Yes No

How many medications to you take to treat hypertension (high blood pressure)?

Have you ever been diagnosed with Type 1 or Type 2 diabetes? Yes No

Do you actively use nicotine products, including vapor cigarettes or patches? Yes No