Welcome to the BREEZE TRANSPLANTTM online health history questionnaire.
Please answer all questions truthfully, accurately, and completely, as the information you provide here will be used by our Transplant Team to detect any medical conditions that may affect your ability to donate a kidney.
This questionnaire is considered extremely confidential. Only health professionals on the Transplant Team will use this information. This information will not be shared with the recipient or others. It is confidential.
This survey will take approximately 15-20 minutes to complete. You must complete the survey in a single session, and we recommend you use a desktop or laptop computer for best results.
Your Name (as printed on your driver's license)
You must enter your full name to certify your legal consent.
.
First
txtFirstName textfield
.
Middle (if applicable)
txtMiddleName textfield
You must enter your full name to certify your legal consent.
.
Last
txtLastName textfield
.
Your Maiden or Former Name (optional)
txtMaidenName textfield
You must enter your date of birth and you must be between the ages of 17 and 69 to proceed.
Your Birth Date
dob textfield
You must select your gender to proceed.
Your Gender
sexFemale radiobutton
You must select your height to proceed.
Your Height
(feet) (inches)
heightInches listchoice
You must enter your weight to proceed, and your weight must be greater or equal to 60 pounds and below 700 pounds.
Your Weight
(lbs)
weight textfield
Please provide your primary phone number and type.
Primary Phone
phonebesttype listchoice
Your email address appears to be incorrect.
Your email address (optional)
txtEmail textfield
You must select a donor type to proceed.
Donor Type
donortype.altruistic radiobutton
You must enter the recipient's legal first name.
Recipient's Legal First Name
txtRecipientName textfield
You must enter the recipient's legal last name.
Recipient's Legal Last Name
txtRecipientLastName textfield
Recipient's Birth Date (optional)
dobRecipient textfield
You must indicate your agreement with the terms of use to proceed.
Terms of Use and wish to proceed
chk itemchoice
.
nextButton imagechoice
The information collected in this survey is strictly confidential and protected by Federal Law. Results are transmitted back to your health care providers.

page id: utah.transplant.kidney/transplant-landing-page;
xnid: unknown;
BREEZE.git: v1.12.1-62-g9a927cc
b.cfg.git: rx.smxn.20160908-49-g15701e5

Please answer the following questions before continuing: