DIALYSIS – MEDICAL REPORT NAME CHRISTIAN NAME DATE OF

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DIALYSIS – MEDICAL REPORT NAME CHRISTIAN NAME DATE OF

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Dialysis – Medical Report

Name:___________________________ Christian name:____________ Date of birth:___________________

Address:_____________________________________________________________________________________

Telephone/Fax:_______________________________________________________________________________

Relatives ( name, address, telephone-no. ):__________________________________________________________

Health Insurance Company:_____________________________________________________________________

Diagnoses:___________________________________________________________________________________

____________________________________________________________________________________________

Regular dialyses since :_____________ Last dialysis before cruising: __________________________________

Duration of dialysis: _______ Frequency of dialysis _______ per week

Dialysis machine :_________ Dialyser:__________________ Cannula used: __________________

Blood flow /min:____________ Heparin/Fragmin-dosage:_____________ Erypo:__________________

Dialysate: Na_____mmol/l K_____mmol/l Ca_____mmol/l Glucose_____mg/dl

Bicarbonate O Acetat O

Shunt/Graft: _________________________________________________________________________________

Shunt problems:_______________________________________________________________________________

____________________________________________________________________________________________

Weight after dialysis ( dry weight ):_____ weight increase between dialyses: ____ Residual diuresis/day:________

Blood pressure pattern:_________________________________________________________________________

____________________________________________________________________________________________

Blood sample analysed on:__________

K_____mmol/l Na_____mmol/L Ca_____mmol/l Phosphate_____mmol/l

SGOT_____U/l SGPT_____U/l Crea._____mg/dl Urea _____mg/dl

HBs Ag:______ HBs Ak:______ HIV:_____

Anti HCV: ______ if pos. Þ Polymerase reaction C-Virus-RNA _____

Blood group :_________________ irreg. antibodies:__________ Haematocrit___________

Number of blood transfusions within the last two months:______

Chest X-ray:_________________________________________________________________________________

____________________________________________________________________________________________

ECG :_______________________________________________________________________________________

____________________________________________________________________________________________

Current medications

1.______________________________________ 6.____________________________________________

2.______________________________________ 7.____________________________________________

3.______________________________________ 8.____________________________________________

4.______________________________________ 9.____________________________________________

5.______________________________________ 10.____________________________________________

Diet:________________________________________________________________________________________

Peculiarities:_____________________________________________________________________________________________________________________________________________________________________________

Medical objections to the patient´s joining the cruise:_________________________________________________

____________________________________________________________________________________________

Name and address of the dialysis doctor: __________________________________________________________

Telephone/Fax: _______________________________________________________________________________

Nature of dialysis: center O limited care O home O

___________________________________

Signature of dialysis doctor

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DOMUS NOVA HOSPITAL DIALYSIS CENTRECAD VIA P PAVIRANI 44

Tags: christian name:____________, name, report, christian, dialysis, medical

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DIALYSIS – MEDICAL REPORT NAME CHRISTIAN NAME DATE OF