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.
You must enter your full name to certify your legal consent.
Your First Name
txtFirstName textfield
You must enter your full name to certify your legal consent.
Your Last Name
txtLastName textfield
You must enter your date of birth and you must be between the ages of 18 and 80 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
An accurate, recent weight is required. Please weigh yourself.
Please provide your primary phone number and type.
Primary Phone
phonebesttype listchoice
Your email address appears to be incorrect.
Your email address
txtEmail textfield
You must select a donor type to proceed.
Donor Type
donortype.altruistic radiobutton
You must enter the recipient's name.
Recipient's First Name
txtRecipientName textfield
You must enter the recipient's name.
Recipient's Last Name
txtRecipientLastName textfield
You must enter the recipient's date of birth to proceed.
Recipient's Birth Date
dobRecipient textfield
(if available)
You must indicate your agreement with the terms of use to proceed.
Terms of Use and wish to proceed
chk itemchoice
Educational materials can be found here and will be provided again at the end of the survey.
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nextButton imagechoice
This is a secure HIPAA compliant website. All information is strictly confidential and will be shared with your healthcare providers.

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Please answer the following questions before continuing: