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A PROJECT OF
ROOMI FOUNDATION
A PROJECT OF
ROOMI FOUNDATION
A PROJECT OF
ROOMI FOUNDATION
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Kidney Recipient
Don’t take your organ to heaven
Heaven knows we need them her
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Kidney Recipient
Recipient Personal Details
First Name
Last Name
Father/Husband Name
Address
Country
Select Country
Pakistan
Overseas
Province
Select Province
District
Select District
Gender
Select Gender
Male
Female
Transgender
CNIC No.
Date of Birth
Age
Email
Mobile No.
Landline No.
Occupation
Height (cm)
Body Weight (kg)
Next of Kin Details
Name
CNIC No.
Relationship with Recipient
Select Relationship
Father
Mother
Son
Daughter
Brother
Sister
Husband
Wife
Address
Country
Select Country
Pakistan
Overseas
Province
Select Province
District
Select District
Mobile No.
Landline No.
Email
History of Medical illness of Recipient
High Blood Pressure / On Treatment for Hypertension
Select Option
Yes
No
Diabetes / On Treatment for Diabetes
Select Option
Yes
No
Active Hepatitis B (PCR +ve)
Select Option
Yes
No
Active Hepatitis C (PCR +ve)
Select Option
Yes
No
HIV
Select Option
Yes
No
History of Drug Abuse (in last ten years)
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Yes
No
History of Cancer
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Yes
No
History of Regular Alcohol Intake
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Yes
No
Any Other Disease
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Rheumatiod Arthritis
SLE
Chronic UTI / Kidney Disease
STDs (Sexually Transmitted Disesases)
CMV infection
Select Option
Yes
No
Sphilis
Select Option
Yes
No
For Kidney Recipient
Blood Type
Select Option
A
B
AB
O
HLA Tissue Typing
HLA - A
HLA - B
HLA - C
HLA DRB1
DQ
PRA (Panel Reactive Antibodies)
Select Option
0-10% (Good)
10-50% (Moderate)
Greater than 50% (Not Recommended)
Anti HLA Antibodies
Renal Function Test
Serum Creatinine
Blood Urea Nitrogen (BUN)
Glomerular Filtration Rate (GFR)
Upload Renal Report File (PDF, PNG, JPG, JPEG):
Renal Remarks
Ultrasound KUB
Upload Ultrasound KUB Report (PDF, PNG, JPG, JPEG):
Ultrasound KUB Remarks
Complete Blood Count (CBC)
Hemoglobin (Hb)
Hematocrit (Hct)
White Blood Cells (WBC's)
Platelets
Mean Corpuscular Volume (MCV)
Red Blood Cell Count (RBC)
Electrolytes
Sodium (Na⁺)
Potassium (K⁺)
Chloride (Cl⁻)
Bicarbonate (HCO₃⁻)
IGRA TEST
Select Option
Yes
No
Liver Enzyme
Total Bilirubin
Alanine Aminotransferase (ALT)
Aspartate Aminotransferase (AST)
Coagulation Profile
Prothrombin Time (PT)
International Normalized Ratio (INR)
Endiocardiography Upload File (PDF, PNG, JPG, JPEG):
Submit Details
