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Today's Date
Completed By
Please leave this field empty. Patient Name
Date of Birth (MMDDYY)
Address
Dialysis Center
Last Dialysis Treatment
Nephrologist
Dialysis Center Phone
Dialysis Center Fax
Access Type
GraftFistulaCatheter
Access Location
RightChestForearmUpper ArmLeftThighGroinEvaluate and Treat
Service Requested
0%
Clotted Access - Date Clotted:
Cold/Numbness/Pain
Recirculation
Infiltration
Non-Maturing Fistula
Aneurysm
Low BFR
Difficult Cannulation
Abnormal Functional Studies
Weak Thrill/Bruit
Prolonged Bleeding
Swollen Extremity Studies
Low Kt/V
Other:
33%
Date of insertion:
Facility Where Placed:
Type: TunneledNon-tunneled
Site: LeftRightIJGroinSubclavian
Desired Procedure: InsertionCatheter ExchangeRemoval
Indication: ClottedPoor FunctionBroken CatheterNo Longer RequiredExchange temporary catheter for permanent catheterOther:
66%
X-Ray Contrast Allergy? YesNo
Reaction:
Diabetic? YesNo
If yes, is the patient on insulin?
Anticoagulants? YesNo
If yes, what type?
Competent to Sign Consent? YesNo
If no, whom?
Is the patient ambulatory? YesNo
Wheelchair? YesNo
Stretcher? YesNo
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