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Patient's Information Form

This form is quite extensive and all the fileds are mandatory, if you do not have info for a certain field, please indicate NA in that field.

Patient's Information:
1. Name:
2. Age:
3. Sex
4. Address:
5. City:
6. Postal Code:
7. Country:
8. Home Phone:
9. Mobile Phone:
10. Email:
Blood test information:
11. Date of Test:
12. Hemoglobin:
13. Blood Urea:
14. Serum Creatinine:
15. Serum Calcium:
16. Serum Sodium:
17. Serum Potassium:
18. Serum Phosphorus:
19. Blood Sugar:
20. Serum Uric Acid:
 
Please answer the following questions:
21. How is your appetite?
22. Is there any constipation or loose stool?
23. Is there any nausea or vomiting?
24. Is there swelling? (on feet, legs, face etc.)
25. Do you have breathlessness?
26. Do you feel weak?
27. What are your liquid intake? ml
27a. What is the liquid output? ml
28. Are you experiencing itching?
29. What is your current Blood Pressure? Systolic Diastolic
30. Are you on dialysis?
31. Are you diabetic?
32. Do you have family history of kidney disease?
33. Are you allergic to any food, medicine or weather?
34. Ultra sound scan of abdomen? (please indicate results from report)
35. What medicine (s) are you currently taking?
36. Additional info
37. How did you hear about us?
 
 

 
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