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Requested
Illustration:
1.
WHAT DISORDER MADE THE KIDNEY TRANSPLANT
NECESSARY?
KIDNEY FAILURE DUE TO DIABETES
KIDNEY FAILURE DUE TO GLOMERULONEPHRITIS
KIDNEY FAILURE DUE TO POLYCYSTIC KIDNEY DISEASE
OTHER
2.
DATE OF THE TRANSPLANT
3.
SOURCE OF TRANSPLANTED KIDNEY:
IDENTICAL TWIN
RELATED DONOR WITH IDENTICAL HLAPHENOTYPIC MATCH
RELATED DONOR WITHOUT IDENTICAL HLAPHENOTYPIC MATCH
NON-RELATED LIVE DONOR
NON-RELATED CADAVER KIDNEY
4.
PLEASE GIVE RESULTS OF MOST RECENT KIDNEY
FUNCTION;
BUN
SERUM CREATINE
URINALYSIS
5.
PLEASE NOTE IF ANY OF THE FOLLOWING HAVE
OCCURRED (CHECK ALL THAT APPLY):
FREQUENT INFECTION
REJECTION EPISODES
HIGH BLOOD PRESSURE
CARDIOVASCULAR DISEASE
TOXICITY FROM TREATMENT
CANCER
DISEASE RECURRENCE BLOOD PRESSURE
6.
ARE THERE ANY CURRENT SYMPTOMS OR COMPLICATIONS?
IF YES, DETAIL DATE AND RESULTS:
7.
WHAT TREATMENT IS CURRENTLY BEING PRESCRIBED?
LIST MEDICATION AND DOSAGE
8.
WHEN WAS THE LAST TIME A PHYSICIAN WAS CONSULTED TO FOLLOW UP ON THE TRANSPLANT?
9. CLIENT'S OCCUPATION
10. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL
11. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL
12.
PLEASE LIST ANY OTHER ILLNESSES OR
IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:
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