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Information provided will be kept strictly confidential.
(If you have any questions please do not hesitate to call us at 718-431-9831).
First Name :
Middle :
Last Name :
ABO (Blood Type) :
O
A
B
AB
unknown
+
-
Height :
Feet
inches
Weight :
lbs
kg
Gender :
Male
Female
Date of Birth :
Age :
Address :
Email :
City :
State :
Zip Code :
Phone :
Alternate Phone:
Work
Cell
Current Work Status:
Employed
Self-Employed
Homemaker
Unemployed
Student
Marital Status :
Single
Married
Divorced
Renal History :
What is the cause of your kidney failure?
Dialysis
Yes
No
When did you start dialysis?
How you do you receive dialysis?
Hemodialysis?
Peritoneal Dialysis?
Have you ever had a transplant? If yes,
When?
Where?
Did you have your native kidneys removed?
Yes
No
Have you ever had blood transfusion?
Yes
No
Family history:
Mother living:
Yes
No
If deceased – Cause
age
Father living :
Yes
No
If deceased – Cause
age
Children :
Number living
Health status
Number deceased
Cause of death
Siblings :
Number living
Health status
Number deceased
Cause of death
Has anyone in your family ever had :
Kidney Disease
Yes
No
Stones?
Yes
No
If yes, who? (How are they related to you?)
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