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Nephrologist: (kidney specialist) Today's Date: Do you have any problems with any part of your urinary system? (Please describe) Primary Care Physician:Insurance Plan(s): PCP location:Men or women, do you have a problem with sexual dysfunction? Phone number if not BWH: Any family history of kidney disease? Have you been started on Epogen/Procrit/Aranesp? (please circle) How much urine do you produce per day? Family member(s) affected:When?Is it frothy, bloody or an unusual color? What was the cause? Have you ever had kidney stones? Pharmacy name and phone number:Height: Weight:If yes, how were they treated? Do you have any problems with your glandular system? (thyroid, pituitary, adrenal) (Please describe) Do you have any of the following conditions? (Check all that apply) High Blood Pressure Heart Disease Stroke Diabetes Cancer Peripheral Vascular Disease Female patient, do you still menstruate? No Yes What is your pregnancy history? Chronic Obstructive Pulmonary Disease Psychiatric Disorder GI Problems Inflammatory Bowel Disease High Cholesterol Obesity Pancreatitis Bone Disease When was your last Pap smear?Mammogram? Have you been hospitalized in the past two years? No Yes Do you have any problems with your muscles, joints, bones? (Please describe) List the reasons for the above hospitalizations: Do you have any prosthetic devices? How many prescription medications are you taking? 0 - 3 4 - 6 7 + Please list: Do you have questions regarding any of your medications? No Yes Do you live alone? No Yes Do you have any problems with your skin? (Please describe) If no, does anyone live with you who is ill, disabled, dependent or non-supportive? No Yes How do you rate your overall health? Excellent Good Fair Poor Do you feel you have any problems with anxiety, depression or other psychological issues? (Please describe) Do you need assistance with any of the following? Shopping Meal Prep Eating Bathing Toileting What helps you to cope? Dressing Walking Medications Housekeeping/Laundry Telephone Access Getting into or out of bed Transportation Making Appointments Have you ever felt unsafe or been afraid of anyone? (Please describe) Do you take any medications for anemia such as Procrit, Epogen or Iron? (please list) Do you use any nutritional supplements? (please list) Do you take any medications to regulate your blood pressure? (please list) Has anyone ever hurt or threatened to hurt you or someone that you care about? Do you experience pain as a part of your daily life? No Yes - Where? Do you take any medications to help prevent bone disease? (please list) When does it start?How long does it last? Allergies: Diabetes type: (if applicable)Insulin dependent? No Yes What are the characteristics of your pain (e.g. ache, burn, throb, sharp, dull)? Have you had a previous kidney transplant? No Yes - When?Type: Cadaver Living related Living non-related Do you speak/understand English? No YesPrimary language: Have you ever had surgery of any type? (Please list)If yes, on a scale of 1-10, 10 being the greatest, how would you rate this pain? Do you have a history of falling (of falls)? If yes, please describe: Have you ever smoked cigarettes, been dependent on alcohol and/or recreational drugs? (Please describe) Has transplantation ever been discussed with you? No Yes Are you interested in transplantation? No YesWhat type? Living related Living non-related Cadaver Do you have any problems with your eyes, ears, nose or throat? (Please describe) Have potential donors started the evaluation process? No Yes Is there any health issue that you would like to see addressed? No Yes (Please describe) Do you have any trouble chewing/swallowing food? (Please describe)Did you receive a copy of the" We Care About Your Safety" brochure? No Yes Do you understand how to prevent the spread of germs? No Yes Do you have dentures? No Yes Do you have any problems with breathing? (Please describe) Do you use oxygen? No Yes - When? Do you have any problems with your heart or circulation? (Please describe) Do you have an appointment with a surgeon for vascular access placement? No Yes - When is it scheduled? Do you have any problems with your digestion or bowels? (Please describe) Patient Signature:Date: Do you take any "Over the counter" Vitamins and/or Herbal medications? (Please list) Do you have any prosthetic devices? How many prescription medications are you taking? 0 - 3 4 - 6 7 + Please list: Do you have questions regarding any of your medications? No Yes Do you live alone? No Yes Do you have any problems with your skin? (Please describe) If no, does anyone live with you who is ill, disabled, dependent or non-supportive? No Yes Do you use any nutritional supplements? (please list) Do you take any medications to regulate your blood pressure? (please list)Has anyone ever hurt or threatened to hurt you or someone that you care about? Do you experience pain as a part of your daily life? No Yes - Where? Do you take any medications to help prevent bone disease? (please list) When does it start?How long does it last? Allergies: Diabetes type: (if applicable)Insulin dependent? No Yes What are the characteristics of your pain (e.g. ache, burn, throb, sharp, dull)? Have you had a previous kidney transplant? No Yes - When?Type: Cadaver Living related Living non-related Do you speak/understand English? No YesPrimary language: Have you ever had surgery of any type? (Please list)If yes, on a scale of 1-10, 10 being the greatest, how would you rate this pain? Do you have a history of falling (of falls)? If yes, please describe: Have you ever smoked cigarettes, been dependent on alcohol and/or recreational drugs? (Please describe) Has transplantation ever been discussed with you? No Yes Are you interested in transplantation? No YesWhat type? Living related Living non-related Cadaver Do you have any problems with your eyes, ears, nose or throat? (Please describe) Have potential donors started the evaluation process? No Yes Is there any health issue that you would like to see addressed? No Yes (Please describe) Do you have any trouble chewing/swallowing food? (Please describe)Did you receive a copy of the" We Care About Your Safety" brochure? No Yes Do you understand how to prevent the spread of germs? No Yes Do you have dentures? No Yes Do you have any problems with breathing? (Please describe) Do you use oxygen? No Yes - When? Do you have any problems with your heart or circulation? (Please describe) Do you have an appointment with a surgeon for vascular access placement? No Yes - When is it scheduled? Do you have any problems with your digestion or bowels? (Please describe) Do you take any "Over the counter" Vitamins and/or Herbal medications? (Please list) |