Form No. 2- Series Aug 2007 Donat, Regs use only CASE NO, Encode 1 Date Review ____ Date Revision requested [les No HEMODIALYSIS REGISTRY evenean ee, Philippine Renal Disease Registry Enoode2.———_Date —— [DOHINKTI Rena Disease Contol Program - Philpine Socey of Nephrology HOSPITALIDIALYSIS UNIT _ DATE COMPLETED (mmidd/yyyy) io COMPLETED BY ENTRY FORM FOR EVERY PATIENT STARTED ON HEMODIALYSIS [NOTE PLEASE ANSWER ALL QUESTIONS COMPLETELY AND ACCURATELY pauwweatTa nuweer 11-1 TTT TTI White ‘Mid Eastem/Arabian PERMANENT ADDRESS: PRESENT ADORESS: __ NAME OF RELATIVE NOT LIVING WITH THE PATIENT. ‘ADDRESS: CONSULTANT /NEPHROLOGIST:: emistatus: (_] single [1] maried [1] widow [7] seperated astname CT TTT i [cL FIRSTNANE [ aa wrapaa DETTE) |e a Pear oe see mooie name TT TTT TET TTTTTTiTTtitt) posited Asian (Non Flpino) 7) others, DATE OF BIRTH ‘SEX:[]Male [“]Female as a eal TAG Ci onan Baar Comele C1 Maced! Unknown Pacific islander TEL. NO: TEL. No: TEL No: 4. PRIMARY RENAL DISEASE (CAUSEOF END STAGE RENAL DISEASE) Do not write ESRD, CRF, CKD, ARF CGN Biopsy proven, Specify COGN Clinical (RBC cast OR proteinuria >2 gramsiday) CPN Biopsy proven OR with racologc evidence of reflux nephropathy CPN Clinical History of UTI or urolthiasis) Ci Hypertensive Nephrosolerosis, biopsy proven Hypertensive Nephrosclerosis clinical (Hypertension ‘precedes ESRD by at least 5 years) Cl Autosomal Dominant Polycystic Kidney Disease C Diabetic Nephropathy 3 Opes 2 cattle EASE BEA one) Dont write Anemia, Urerria None Diabetes Melitus Cl Hypertension PTB, active by Chest X-Ray corp Ischemic Heart Disease, (notin CHF) defined as: Previous Myocardial Infarction Angina pectoris, unstable angina ~ Medications (nitrates, etc.) {C Congestive Heart Failure (any etiology) 1D Stroke (Cerebrovascular Accident) G Colagen Disease, Specify... 1D Malignancy, Specty * Scout 1 Others, Speciy 3, YEAR WHEN INITIAL DIALYSIS FOR ESRD WAS STARTED 0000 RDC2007-06-06 4, AGE OF PATIENT WHEN 1ST DIALYSIS TREATMENT FOR ESRD WAS STARTED [_][_] yrs. 5, DATE HEMODIALYSIS. STARTED IN PRESENT UNIT (omiddyw) (1/0 /OoOoOo 6. MOST COMMON TYPE OF HD PROCEDURE USED D1 Conventional O High Fiux High Efciency 7. MOST COMMON DIALYSIS BATH USED OD Acetate Bicarbonate 8, AVERAGE DURATION OF EACH DIALYSIS SESSION Less than or equal to three (3) hours 1D Between 3 up to 4 hours, G More than 4 hours C Others, Specity 9. HEPATITIS B STATUS CLHBsAg (+) positive CHBsAg (-) negative Not done / data not available 10, HEPATITIS C STATUS Cl Ani:HCV (+) positive G Anti-HCV (-) negative 1 Not done / data not available | ‘11. IS PATIENT ON ERYTHROPOIETIN? Dyes (CUALPHA C1BETA Cl DARBEPOIETIN: Route: [ euboutaneous = IV ONoGUIDE TO CLASSIFICATION OF ETHNICITY White A person having origins in any ofthe original white people of Europ, Black - A porson having origins in any of the black racial groups of Aca Filipino - person tidvng origin inthe Philippines. Check this for al pure Filpins & Filipinos with foreign blood <25%, ‘Asian (Non Flipino)-A person having origins in any ofthe orignal peoples ofthe Far East and Southeast Asia ‘other than the Philippines, Check his if both parents Asian but not Filpino. Pacific dander - & parson having orgins in any of the folowing peoples ofthe Pacific Islands. Example of these ‘areas include the Samoa and Hawatian islands. Mid-EastemiAcabien -A person having ofigis in any ol the paoples ofthe Middle East and Northern Ai include Eaypl, Israel, ran, faq, Saudi Arabia, Jordan, and Kuwal Indian Sub-Continent-& person having origins in any ofthe peocles ofthe Indian Sub-continent, Examples ofthese areas include India, Pekisian, Sri Lanka, and Sengladesh Mixed Flipino - Check this for Filipinos with foreign blood > 25% ‘Mixed Nor-Filpina - Check this i nether parent is Filing (Other, specity -Aperson rot having origins in any of the above categories. Write race(s) in space provided. ‘Unknown - Check this box ifrace is unknown. ples of these areas, PRIMARY RENAL DISEASE: mak he apgroprate box to indicate the cause ofthe patient's End Stage Renal Disease ‘The patients Attending Physician should provide ths information Ifthe cause of the cenal disease isnot in the lst, write it on he space beside others & specily. Check UNKNOWN if the causo of the Chronic Renal Disease could not be determined. Please do not write ESRD, ARF, CKD, ORF. CO-EXISTING DISEASE: mark the aoproprite box to indicate the presence or absence of co-existing systemic disease in the patient, ifthe co-existing systemic disease is notin thé list, write ion the space beside others & specify. The patient's ‘Attending Physician should provide the information, Please do not include entities that may be related to the chronic renal disease of the patient je, anemia, uremia, YEAR WHEN THE INITIAL DIALYSIS FOR ESRD WAS STARTED : write the year when the patient was started on any form of clalysis either HD of PO) for ESRD for the very 4st ime in his entire if DATE HEMODIALYSIS STARTED IN PRESENT UNIT: wile the date when patient was fist dialyzed in your Unit in the order of Month, Day and Year, MOST COMMON TYPE OF HD PROCEDURE USED: mark the appropriate box to indcate the type of HO prooedure used {or the palient on regular sessions. corwentional, high flux 0: high eficiency. CONVENTIONAL HD: dielysis procedure utlizing dalyzers with homogenous membranes tha can eifectively clear smal sized solute ‘and low clearance for medium sized solutes. Examples of Dialzers used in Conventional HD - F4, F5, HE 1200, LO PS 12, 15, 18 HIGH EFFICIENCY HD: dialysis which is eimilar to tho High Flux procedure which utlizes cialyzers that can effectively lear ow ‘molecular weight solutes better than conventional ype. However the dalyzers have modiied hydraulic permebiiy thus reducing its capacity o clear large or high molecular veight solutes. Examples of High Efficiency Dialyzers:F6, FB HIGH FLUX HD: dialysis procedure which can offectively clear both smell and large molecular weight solutes (82 microglobulin). The procedure requices the use of dalyzers with highly permeable synthetic or motified cellulosic membranes. Examples of High Flix Dialyzers: 40, FEO, F80, HIPF 12. NOTE: This form is ONLY for patients newiy diagnosed to have ESRD. “This form s NOT for patents 1. Diagnosed to have ACUTE RENAL FAILURE 2. Who are rat permanent Phippine residents iia. addresses not within Philippine terntory, transionts (Balkbayans, Foreigners)