HOLIDAY DIALYSIS REQUEST
(to be completed by doctor or dialysis unit staff)
PERSONAL DETAILS:
Name:
Surname:
Date of birth: / /
Home / postal address:
Tel:
Contactable relative:
Relationship: Tel:
Arrival date on vacation:
Departure date:
Address while on vacation:
Telephone number while on holiday:
Name and address of your dialysis unit:
Nephrologist: Dr.
Tel: Fax:
Cause of renal failure:
Other medical problems:
On dialysis treatment since: / /
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BLOOD TEST-SEROLOGY:
Hepatitis B (HBSAg): Neg./Pos. on: / /
Hepatitis B (HBSAb): Neg./Pos. on: / /
Hepatitis B (HBcAb): Neg./Pos. on: / /
Hepatitis C(HCV) o:Neg./Pos. on: / /
Hepatitis C RNA-PCR HVC: Neg./Pos. on: / /
HIV: Neg./Pos. on: / /
MRSA Swabs: Neg./Pos. on: / /
Hb: g/dl on: / /
Urea: mgs/dl on: / /
K: mEq/L: on: / /
Calcemia: mgs/dL: on: / /
Fosfatemia: mgs/dL: on: / /
ALT: UI on: / /
AST: UI on: / /
Please include copies of lab latest Hepatitis B (HbsAg, AntiHBS e AntiHBC), C, HIV and MRSA blood test results.
Known allergies:
DIALYSIS DETAILS
Type: HD: HDF ONLINE:
Dialysis duration: hours/ore
frequency /week.
Access type:
1) AV fistula /Graft Left Right
Needle size: gauge.
2) Permanent catheter:
Heparin lock volume : A ml V ml.
Dialyser: Dialysate flow:
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Dialysate: K Ca Na
Low molecular weight heparin:
Generic name: dose/dosaggio:
Or
Sodium heparin:
Initial bolus: u; hourly: u.
or continuously: u/hour.
Blood flow: ml/min; Average intake on dialysis: ml.
Height: mt; Weight: ml.
Dry weight: kg; Avg interdialytic gain: kg.
Blood Pressure: pre / post /
DIALYSIS PROBLEMS:
Hypotension Cramps Other:
Last results for dialysis adequacy:
Kt/V or URR: Date: / /
Current medication:(please include brand names and generic names of drugs)
EPO: close frequency:
Antihypertensives:
Phosphate binders:
Other:
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History and Physicals-Special Requirements:
Payment method:
Cash: EHIC N°:
Expiry date:
(please include a cleare/well readable copy of the EHIC card both sides)
Pre payment by bank transfer:
Other relevant information e.g medical insurance details:
Transplant List:
since: / /
Signature
(Doctor / Sr in charge)
Date/: / /
N.B. This form has to be filled in in every part, if not, receiving holiday nephrologist could deny the booking, being important information on the dialysis performed by travelling patient missing.
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Informativa ai sensi del D.Lgs. n. 196/03 – Normativa sulla Privacy. Holiday Dialysis International. corrente Palazzo Pignano, Via Crema 8, Titolare del trattamento, informa che, salvi i diritti di cui agli artt. 7, 8, 9 e 10 D.Lgs. n. 196/2003, i dati raccolti con la presente scheda sono destinati ad essere trattati, nel pieno rispetto dei dettami normativi vigenti. I dati medesimi saranno utilizzati unicamente per gli scopi indicati e non saranno comunicati a terzi o diffusi.