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Kidney Assessment form

Name:
Phone:
Age:
email:
Gender:
Country:
Lab Investigation
Date of Test:
Hemoglobin:
Serum Creatinine:
Blood Urea:
       
Additional Health Questions
Your liquid input and output in 24 hours?
Intake: Output:
Are you on dialysis?
How long have you been on dialysis?
Any additional Information that you would like to share?
How did you hear about us?