Assessment Form

Contact Information
1. Name:		6. State:
2. Age:		7. Postal Code:
3. Sex:		8. Country:
4. Address:		9. Phone:
5. City:		10. Phone (Cel/Mobile):
		11. eMail Address:

Lab Investigations
Date of Test:	DD-MM-YYYY
1. HB:		5. Serum Uric Acid:
2. TLC:		6. Blood Urea:
3. DLC:		7. Serum Creatinine:
4. Blood Sugar:
* TLC and DLC stands for Total and Differential Leucocyte Count.
Electrolytes
1. Sodium:		3. Potassium:
2. Calcium:		4. Phosphorus:

Additional Reports
1. Urine Routine Test:
2. Ultra Sound Abdomen with Kidneys:

Additional Health Questions
1. Your blood pressure?	Systolic :	Diastolic:
2. Are you diabetic?
3. Any family history of kidney disease?
4. Are you allergic to any food, medicine or weather?
5. Your liquid input and output in 24 hours?	Intake:	Output:
6. How is your appetite?
7. How is your bowel movement?
8. Do you feel any nausea or vomiting?
9. Do you have any breathlessness?
10. Do you feel weak?
11. Do you have any itching?
12. Is there any swelling on face, legs or feet?
13. Are you on dialysis?
14. How long have you been on dialysis?
15. If it is Heamodialysis - what is the frequency?	/Week
16. Please list medicine(s) that you are currently taking.
17. Any additional Information?
18. How did you hear about us?
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Kundan Kidney Care Centre

Assessment Form